EXAMINATION QUESTION ON OPERATIVE SURGERY AND TOPOGRAPHIC ANATOMY FOR FOREIGN STUDENTS
Common questions
1. Subject and aims of topographic anatomy and operative surgery. Topographo-anatomical region, external landmark, projection.
Topographic anatomy is a science about mutual location and
interrelation of organs and tissues according to the regions of human
body.
Operative Surgery is a medical science about techniques, methods and rules about performing operations and the usage of surgical instruments.
Topographical anatomy is a clinically applied morphological science. The doctors in each specialty need the knowledge of its achievements but the surgeons are directly interested in it. That is why this science is studied together with operative surgery. Topographical anatomy and operative surgery is ‘one in two science’, often named ‘surgical anatomy’ because without the knowledge about peculiarities and variants of structure, form, location and mutual location of anatomical structures, their age-specific and sexual properties, it is impossible to diagnose in the proper time and correctly and to prescribe the necessary treatment to the patients.
Topographo-anatomical region is a part of human’s body with its
own structure, separated from neighbor regions by the conventional or
natural borders.
External landmark is an anatomical formation (bony prominence,
dermal fold, muscle), permanent to this region.
Projection is a point, line or geometrical figure, which is drawn
according to the external landmark and corresponds to deep structures.
2. Surgical instruments, classification, rules of use.
Surgical instruments are the tools with the help of which the
surgeon manipulates on tissues and organs while performing the
operation.
Kinds:
Common – are used in any surgical operation.
1. For disconnection of tissues (cutting instruments: surgical
cutters: bellied scalpel, sharp-pointed scalpel, scalpel with a removable
(single-use) blade; scissors).
2. Auxiliary instruments (anatomical pincers, gripping pincers,
surgical pincers; hooks: pronged, blunt and sharp hooks; dilators;
retractors, surgical clips).
3. Haemostatic instruments (two-toothed Kocher's, Billroth's,
mosquito straight or curved forceps).
4. For connection of tissues (suture needles, suture filaments,
needle-holders).
Special – are used in certain surgical operations (instruments for
trepanation, amputation).
For the list of surgical instruments:
3. Classification of operations. Main rules and stages of surgical operation.
Classification of operations
According to time:
a. emergency operation is carried-out upon vital indications (in case of bleeding from magistral vessels, mechanical asphyxia of respiratory tracts by foreign bodies);
b.urgent operation is carried-out after exacted [clarified] diagnosis (in case of strangulated hernias, perforated ulcer, appendicitis);
c. elective operation is carried-out after full and meticulous examination of a patient and precise diagnosis (cholecystectomy in case of gall-stones).
According to aim:
a. diagnostic [explorative] surgery – to establish diagnosis;
b. treatment surgery – to remove lesion focus.
According to recovery of a patient:
a. radical operation is directed at complete treatment of the disease or curative surgery (appendectomy, amputation of extremity in case of gangrene);
b. palliative operation is directed at temporary relief of the patient's condition and saving his life (decompressive trepanation for reduction of intracranial pressure, gastrostomy in case of inoperable tumor of esophagus).
According to stages:
a. single-stage operation is performed in one stage during which all the necessary measures are taken to treat the disease;
b. double-stage operation is performed in such cases when the condition of a patient or danger of possible diseases doesn’t allow to finish operation in one stage;
a. Multistage operation is usually used in plastic surgery when reconstruction of a damaged part of human body is done in several stages.
Special surgical operations:
a. microsurgical operation is done under magnification of operating microscope or surgical loupe with the help of special microsurgical instruments and suture material by diameter 6/0-12/0 (sutures of vessels, nerves);
b. endoscopic operation is done with the help of special apparatus (endoscope) in hollow organs and cavities (laparoscopy, arthroscopy);
c. endovascular operation includes intravascular manipulations under ultrasonic or roentgen control.
Main rules:
1. anatomical availability (incision should be in the place, which provides the immediate approach to the object of surgical operation);
2. technical ability (possibility of secure operation performing);
3. physiological permission (considering the condition of a patient).
Stages of surgical operation
Operative approach, surgical maneuver and reconstruction of organs and tissues.
4. Main rules of disconnection and connection of tissues. Kinds of knots, sutures (skin and muscular sutures).
The rules of disconnection of tissues:
1. layer-by-layer;
2. the same extent of the incision in each layer;
3. parallel disconnection;
4. an incision should be as large, as necessary and as small, as
possible;
5. simple form of the incision.
The rules of connection of tissues:
1. layer-by-layer;
2. connection of similar tissues;
3. strength.
Kinds of knots
A. Simple
B. Surgical
C. Gynecological
D. Hitch
Sutures
A. Interrupted sutures
1. simple
2. z shaped
3. p shaped
B. Continous Sutures
1. Simple
2. Blanket
3. Mattress
4. Multanovsky
5. Fascias of human body. Practical significance.
6. Concept about transplantation of organs and tissues.
Topographic anatomy and operative surgery of limbs
1. Projections of vessels and nerves of the upper limb.
PROJECTIONS OF MAIN NEUROVASCULAR BUNDLES OF UPPER EXTREMITIES
INFRACLAVICULAR
REGION
Subclavian artery, vein and fascicles of brachial plexus are
marked on the middle of clavicle.
DELTOID
REGION
The axillary nerve with its divisions
It is marked as a horizontal line on the deltoid muscle, 2 cm
above the midpoint between the tip of the acromion process and the insertion of
the deltoid.
Intramuscular injections in the deltoid are given in the
lower part of the muscle nearer to its insertion to avoid injury to the nerve
and its accompanying vessels.
Upper lateral cutaneous nerve of the arm goes
on the middle of posterior edge of deltoid.
AXILLARY
REGION
Axillary artery, vein and fascicles of brachial plexus Hold
the arm at right angles to the trunk with the palm directed upwards. The
structures are then marked as a straight line by joining the following two
points:
1. midpoint of the
clavicle;
2. point at the junction of the anterior 1/3 and posterior
2/3 of the lateral wall
of axilla at its lower limit where the arterial pulsations
can be felt.
BRACHIAL
REGION
Brachial artery
It is marked by joining the following two points:
1. Point at the
junction of the anterior 1 / 3 and posterior 2/3 of the lateral wall of the
axilla at its lower limit;
2. Point at the level of the neck of the radius medial to the
tendon of the biceps brachii.
Thus, the artery begins on the medial side of the upper part
of the arm, and runs downwards and slightly laterally to end in front of the
elbow. At its termination it bifurcates into the radial and ulnar arteries.
Median nerve
The nerve is then marked lateral to the brachial artery in
the upper 1/2, and medial to the artery in the lower 1/2 of the arm. The nerve
crosses the artery anteriorly in the middle of the arm.
Musculocutaneous nerve
It is marked by joining the following two points:
1. Point lateral to the
axillary artery 3 cm above its termination;
2. Point lateral to the tendon of the biceps brachii muscle 2
cm above the bend of the elbow. (Here it pierces the deep fascia and continues
as the lateral cutaneous nerve of the forearm).
Ulnar nerve It is marked by joining
the following points:
1. Point at the
junction of the anterior 1/3 and posterior 2/3 of the lateral wall of the
axilla at its lower limit (lower border of the teres major muscle);
2. Point at the middle
of the medial border of the arm;
3. Point behind the base of the medial epicondyle of the
humerus.
Radial nerve
It is marked by joining the following points:
1. Point at the
junction of the anterior 1/3 and posterior 2/3 of the lateral wall of the
axilla at its lower limit;
2. Point at the
junction of the upper 1/3 and lower 2/3 of a line joining the lateral
epicondyle with the insertion of the deltoid;
3. Point on the front of the elbow at the level of the
lateral epicondyle 1 cm lateral to the tendon of the biceps brachii.
The first and second points are joined across the back of the
arm to mark the oblique course of the radial nerve in the radial (spiral)
groove (posterior compartment). The second and third points are joined on the
front of the arm to mark the vertical course of the nerve in the anterior
compartment.
CUBITAL
REGION
Brachial artery
It is marked at the middle of ulnar bend medially to biceps
tendon.
Median nerve
It is marked 1 cm medially to brachial artery.
Radial artery It is marked in a point
located at the middle of distance between lateral and medial epicondyles of
humerus or on the medial edge of biceps tendon.
Radial nerve
It is marked in a point located at the middle of medial edge
of brachioradialis. The place of division of the nerve on superficial and deep
branches is located at the level of head of fibula.
Ulnar nerve
It is marked between olecranon and medial epicondyle of the
humerus.
FOREARM
REGION
It is marked by joining the following two points.
1. Point medial to the
brachial artery at the bend of the elbow;
2. Point in front of the wrist, over the tendon of the
palmaris longus (or 1 cm medial to the tendon of the flexor carpi radialis).
Radial artery
It is marked by joining the following two points:
1. Point in front of
the elbow at the level of the neck of the radius medial to the tendon of the
biceps brachii;
2. Point at the wrist between the anterior border of the
radius laterally and the tendon of the flexor carpi radialis medially, where
the radial pulse is commonly felt.
Its course is curved with a gentle convexity to the lateral
side.
Superficial branch of radial nerve
It is marked by joining the following three points:
1. Point 1 cm laterally
to the biceps tendon at the level of the lateral epicondyle;
2. Point at the
junction of the upper 2/3 and lower 1/3 of the lateral border of the forearm
just lateral to the radial artery;
3. Point at the anatomical snuff box.
The nerve is vertical in its course between points one and
two. At the second point it inclines backwards to reach the snuff box.
The nerve is closely related to the lateral side of the
radial artery only in the middle 1/3 of the forearm.
Ulnar nerve
It is marked by joining the following two points:
1. Point on the back of
the base of the medial epicondyle of the humerus;
2. Point lateral to the pisiform bone.
In the lower 2/3 of the forearm, the ulnar nerve lies medial
to the ulnar artery.
Ulnar artery
It is marked by joining the following three points:
1. Point in front of
the elbow at the level of the neck of the radius medial to the tendon of the
biceps brachii;
2. Point at the
junction of the upper 1/3 and lower 2/3 of the medial border of the forearm
(lateral to the ulnar nerve);
3. Point lateral to the pisiform bone.
Thus the course of the ulnar artery is oblique in its upper
1/3, and vertical in its lower 2/3. The ulnar nerve lies just medial to the
ulnar artery in the lower 2/3 of its course. The ulnar artery continues in the
palm as the superficial palmar arch.
Deep branch of radial nerve
It is marked by joining the following three points:
1. Point 1 cm lateral
to the biceps tendon at the level of the lateral epicondyle;
2. Point at the
junction of the upper 1/3 and lower 2/3 of a line joining the middle of the
posterior aspect of the head of the radius to the dorsal tubercle at the lower
end of the radius (Lister's tubercle);
3. Point on the back of the wrist 1 cm medial to the dorsal
tubercle.
Medial and lateral cutaneous nerves of the forearm
Projection lines of these structures correspond to direction
of ulnar and radial groove of forearm.
Posterior cutaneous nerve of forearm
It is marked by joining the following points:
1. Lateral epicondyle
of humerus;
2. Point between abductor pollicis longus and extensor
digitorum in lower 1/3 of forearm.
HAND REGION
Radial artery
It is marked by joining the following three points:
1. Point at the wrist
between the anterior border of the radius and the tendon of the flexor carpi
radialis;
2. Point just below the
tip of the styloid process of the radius;
3. Point at the proximal end of the first intermetacarpal
space.
In this part of its course the artery runs obliquely
downwards and backwards deep to the tendons of the abductor pollicis longus,
the extensor pollicis brevis, and the extensor pollicis longus, and superficial
to the lateral ligament of the wrist joint. Thus it passes through the
anatomical snuff box to reach the proximal end of the first interosseous space.
Further, it passes between the two heads of the first dorsal interosseous
muscle to form the deep palmar arch in the palm.
Superficial palmar arch
It is formed by the direct continuation of the ulnar artery,
and is marked as a curved line by joining the following points:
1. Point just lateral
and distal to the pisiform bone;
2. Point on the hook of
the hamate bone;
3. Point on the distal
border of the thenar eminence in line with the cleft between the index and
middle fingers.
The convexity of the arch is directed towards the fingers,
and its most distal point is situated at the level of the distal border of the
fully extended thumb.
Deep palmar arch
It is formed as the direct continuation of the radial artery.
It has a slight convexity towards the fingers. It is marked by a more or less
horizontal line, 4 cm long, just distal to the hook of the hamate bone.
The deep palmar arch lies 1.2 cm proximal to the superficial
palmar arch across the metacarpals, immediately distal to their bases. The deep
branch of ulnar nerve lies in its concavity.
Prohibited Area
of The Hand: It is projected on proximal third of thenar (by canavel). Motor
branches to the thenar muscles come from the median nerve in this place.
In the wide sense prohibited area of
the hand is a place where not only motor branch of median nerve is located but
branches of ulnar nerve, ulnar and radial arteries and synovial
sheaths of flexors. It is situated between two lines:
1. Line which is drawn
on antebrachio-palmar fold;
2. Line which is drawn parallel to the first one through the
middle of V metacarpal bone.
PROJECTION
OF JOINTS OF THE UPPER LIMB
Shoulder joint
The anterior margin of the glenoid cavity corresponds to the
lower 1/2 of the shoulder joint. It is marked by a line 3 cm long drawn
downwards from a point just lateral to the tip of the coracoid process. The
line is slightly concave laterally.
Elbow joint
The joint line is situated 2 cm below the line joining the
two epicondyles, and slopes downwards and medially. This slope is responsible
for the carrying angle.
Wrist Joint
The joint line is concave downwards, and is marked by joining
the styloid processes of the radius and ulna.
2. Topographic anatomy of upper limb (infraclavicular, axillary, scapular, deltoid regions; regions of arm, cubital fossa, forearm, hand; shoulder, elbow and wrist joints; fat spaces, ways of pus distribution).
TOPOGRAPHIC ANATOMY OF THE UPPER LIMB
The upper limb consists of shoulder girdle fixed to the thorax and
liberal part of the upper limb including arm (brachium), forearm
(antebrachium) and hand (manus).
Shoulder girdle consists of four regions: scapular, deltoid,
infraclavicular and axillary regions.
In liberal part of upper extremity there are following surfaces:
anterior and posterior surfaces of the arm, anterior and posterior surfaces
of the cubital region, anterior and posterior surfaces of the forearm,
anterior and posterior surfaces of the wrist, hand palmar surface, hand
dorsal surface, fingers regions.
Scapular region
Borders of the region correspond to the scapula.
The skin is thick, not flexible.
The subcutaneous fat is poorly developed.
The superficial fascia is dense.
The deep fascia is thin, covers superficial muscles.
Trapezius and latissimal dorsi muscles cover all the scapula except
lateral part of the infraspinous fossa.
Supraspinous and infraspinous fasciae form osteofibrous
compartments with the back scapula surface.
Supraspinous and infraspinous muscles and fat are situated in the
fossae under the same name. Purulent process from these fossae can
spread into the fat tissue of the axillary fossa, deltoid region and lateral
triangle of the neck.
The scapula
Teres minor (starts from the superior 2/3 of the dorsal surface of
the lateral body of the scapula), teres major (starts from the inferior 1/3
of the dorsal surface of the lateral body and the inferior angle of the
scapula) and subscapular muscles.
Anastomosis round the body of the scapula is formed by the
suprascapular artery (passes together with suprascapular nerve), branch
of the thyrocervical trunk which arises from the first part of the
subclavian artery; deep branch of transverse cervical artery (passes
together with dorsal scapular nerve), another branch of the thyrocervical
trunk; circumflex scapular artery, branch of subscapular artery which
arises from the third part of the axillary artery. These anastomoses
provide collateral circulation through which blood can flow to the limb
when a distal part of the subclavian artery or proximal part of the axillary
artery is blocked.
The deltoid region
The deltoid region corresponds to location of the deltoid muscle.
This muscle forms the round contour of the region and covers the
shoulder joint.
The skin is thick, not flexible.
The subcutaneous fat is poorly developed.
The superficial fascia.
The deep fascia forms fascial compartment for the deltoid muscle
and sends numerous septa between its fasciculi.
The subdeltoid fat space is located between the deltoid muscle and
humeral bone. Basic neurovascular fascicle (posterior circumflex
humeral vessels (anastomose with anterior circumflex humeral vessels)
and axillary nerve), tendons of muscles and synovial bursae are in this
space.
The axillary nerve is a branch of posterior cord of the brachial
plexus (C5-C7) and passes into the subdeltoid fat space through
quadrangular space together with posterior circumflex humeral vessels.
This nerve is commonly involved in shoulder dislocations and in
fractures of surgical neck of the humerus.
Purulent process from subdeltoid fat space can spread into the
axillary fossa, supraspinous and infraspinous fossae.
The infraclavicular region
Borders: upper – clavicle; lower – 3 ribs; internal – external edge
of sternum; external – anterior edge of deltoid muscle.
The skin is thin.
The subcutaneous fat is poor developed, contains cutaneous nerves
which go from the cervical plexus (nn. supraclaviculares), anterior and
lateral branches from the intercostal nerves, cutaneous branches from the
internal thoracic and posterior intercostals arteries.
The superficial fascia.
The deep (pectoral) fascia is thin, covers greater pectoral muscle
and gives numerous septa which divide muscle into fasciculi. The
cephalic vein, deltoid branch of the thoracoacromial artery and one or
two deltopectoral lymph nodes lie in deltopectoral groove under the deep
fascia.
Greater pectoral muscle can be divided into three parts: abdominal,
sternoclavicular and clavicular.
Superficial subpectoral fat space.
Clavipectoral fascia is attached to the clavicle, upper ribs and
coracoid process. Upper part of this fascia is thick and is called the
costocoracoid ligament. Below the lesser pectoral muscle it continues as
suspensory ligament which is attached to the axillary fascia dome and
helps to keep it pulled up. It forms fascial compartment for the lesser
pectoral muscle.
The lesser pectoral muscle.
The deep subpectoral fat space is located between the lesser
pectoral muscle and the deep sheath of the clavipectoral fascia.
In deep layers of the infraclavicular region there are three triangles
within the limits of which the neurovascular fascicle passes (axillary
vessels and branches of brachial plexus): clavipectoral triangle (between
upper edge of lesser pectoral muscle and clavicle), pectoral triangle
(corresponds to lesser pectoral muscle) and subpectoral triangle
(between lower edge of greater pectoral muscle and lower edge of
pectoral minor muscle). There are three parts of axillary artery according
to triangles (first is located in infraclavicular region, other two – in
axillary region).
Following structures are located within the limits of the
clavipectoral triangle: the cephalic vein, branches of the thoracoacromial
artery and anterior thoracic nerves.
The axillary region
Borders: anterior – lower edge of the greater pectoral muscle,
posterior –lower edge of the trapezius muscle, internal – the line which
connects these muscles on the chest, external – the line which connects
these muscles on the internal surface of the shoulder.
The skin is thin, flexible, contains big amount of sudoriferous and
sebaceous glands; in adults it is covered by hair.
The subcutaneous fat is poor developed.
The superficial fascia is thin.
The deep (axillary) fascia is dense at lateral part of the region, in
the centre it is thin with big amount of holes through which skin vessels
and nerves pass.
The axillary cavity (fossa) is pyramidal space.
Walls of axilla:
The anterior wall consists of great and small pectoral muscles.
There are two triangles on the anterior wall within the limits of which
axillary vessels and branches of the brachial plexus pass: pectoral and
subpectoral triangles (see infraclavicular region).
The posterior wall consists of subscapular, teres major and
latissimal dorsi muscles. There are two foramens on the posterior wall of
the axillary fossa: quadrangular and triangular.
Boundaries of the quadrangular foramen: superior – the
subscapular muscle, inferior – the teres major muscle, medial – the long
head of the arm triceps muscle, lateral – the surgical neck of the
humerus. It communicates with the subdeltoid fat space. Contents:
axillary nerve and posterior circumflex humeral vessels.
Boundaries of the triangular foramen: superior – the subscapular
muscle, inferior – the teres major muscle, lateral – the long head of the
arm triceps muscle. It communicates with fat of the scapular region.
Contents: circumflex scapular artery.
The medial wall consists of the upper four ribs with intercostals
muscles and the upper part of the serratus anterior muscle.
The lateral wall consists of the upper part of the humerus shaft,
coracobrachial and short head of the arm biceps muscle.
Contents of the axillary fossa: axillary artery and its branches,
axillary vein and its tributaries, infraclavicular part of the brachial
plexus, five groups of the axillary lymph nodes and axillary fat.
Fat of axillary fossa communicates above and medially with the
lateral fat space of the neck along the axillary and subclavian artery;
below – with the fat space of the arm anterior surface along the brachial
artery and with fat space of the arm posterior surface along the radial
nerve; behind – with the subdeltoid fat space along the axillary nerve and
the anterior circumflex humeral artery and with fat of the scapular
region along the circumflex scapula artery.
Neurovascular fascicle contains the axillary artery, vein and
brachial plexus. Interrelation of these elements changes according to the
level of small pectoral muscle. In clavipectoral triangle the axillary vein
lies lower and medially, fascicles of the brachial plexus – higher and
laterally, the axillary artery – between the vein and fascicles of the
plexus. The superior thoracic and thoracoacromial arteries arise from
the first part of the axillary artery.
In the pectoral triangle the posterior fascicle of the brachial plexus
passes behind the artery; laterally – the lateral fascicle; medially – the
medial fascicle, which separates the artery from the vein. At the level of
the second part of the axillary artery arm nerves arise from the brachial
plexus fascicles: from the lateral fascicle – musculocutaneous and lateral
root of median nerve; from the medial fascicle – medial root of median
nerve, ulnar nerve, medial cutaneous nerve of the arm, medial cutaneous
nerve of the forearm; from the posterior fascicle – axillary and radial
nerves. The lateral thoracic artery arises from the second part of the
axillary artery and passes together with the long thoracic nerve.
The axillary artery in the subpectoral triangle is surrounded by
nerves. In the front there is a median nerve; behind – axillary and radial
nerves; laterally – musculocutaneous nerve; medially – ulnar nerve, arm
medial cutaneous nerve, forearm medial cutaneous nerve and axillary
vein. The subscapular artery (divides into circumflex scapular and
thoracodorsal arteries), anterior and posterior circumflex humeral arteries
arise from the third part of the axillary artery.
Axillary lymph nodes are divided into five groups.
1. Nodes of the anterior (or pectoral) group lie along the lateral
thoracic vessels (i.e., along lower border of small pectoral muscle).
They receive lymph from the upper half of the thorax anterior wall
and from major part of the mammary gland.
2. Nodes of the posterior (or scapular) group lie along the
subscapular vessels, on the axilla posterior wall. They receive
lymph from the posterior wall of the thorax upper half.
3. Nodes of the lateral group lie along the upper part of the humerus
medially to the axillary vein. They receive lymph from the upper
limb.
4. Nodes of the central group lie in the fat of upper part of the axillary
fossa. They receive lymph from the preceding groups and drain
into the apical group.
5. Nodes of the apical (or infraclavicular) group lie deeper than the
clavipectoral fascia, along the axillary vessels. They receive lymph
from the central group and from the upper part of the mammary
gland.
The shoulder joint
The shoulder joint is formed by articulation of the scapula and head
of the humerus. Therefore, it is known as the glenohumeral articulation.
Structurally it is weak joint because the glenoid cavity is too small
and shallow to hold the humerus head in place. Stability of the joint is
maintained by following factors: coracoacromial arch, musculotendinous
cuff and glenoidal labrum.
The capsule is attached to the margins of the glenoid fossa and to
anatomical neck of the humerus. Anteriorly the capsule is
reinforced by three supplemental bands, called superior, middle and
inferior glenohumeral ligaments. Superiorly joint is reinforced by
the coracohumeral ligament.
Syntopy: superiorly there are the coracoacromial arch,
supraspinatus and deltoid muscles; inferiorly there is the triceps long
head; anteriorly there are subscapular, coracobrachial, short head of the
biceps and deltoid muscles; posteriorly the infraspinatus, teres minor and
deltoid muscles are located.
Bursae related to the shoulder joint: subacromial (subdeltoid),
subscapularis, subcoracoid and infrasminatus (all communicate with
joint cavity).
Joint cavity is enlarged due to three recesses: axillar (corresponds
to the anteroinferior part of the capsule), subscapular (corresponds to the
anterosuperior part of the capsule and represents the synovial
subscapular bursa) and intertubercular (represents the synovial sheath
for the tendon of long head of the biceps). These recesses are week
places of shoulder joint and in case of purulent inflammation (purulent
omarthritis) puss can pass into the neighbour regions through these
places. Dislocation endangers axillary nerve which is closely related to
lower part of the shoulder joint.
Region of the arm
Borders: upper – line which connects lower edges of the greater
pectoral and trapezius muscles; lower – line, which is drawn 2 cm higher
than epicondyles of the humerus.
The skin on the internal surface is thin, flexible; on the external and
back surfaces it is thicker.
The subcutaneous fat is individually developed, contains following
cutaneous nerves and vessels: cephalic and basilic veins,
intercostobrachial nerve (lateral branch of the second intercostal nerve),
medial cutaneous nerve of the arm (branch of the medial fascicle of the
brachial plexus), upper lateral cutaneous nerve of the arm (branch of the
axillary nerve), lower lateral cutaneous nerve of the arm (branch of the
radial nerve), posterior cutaneous nerve of the arm (branch of the radial
nerve).
The superficial fascia forms sheaths for cutaneous nerves and
vessels.
The deep (brachial) fascia divides the arm into anterior and posterior
compartments by extensions of deep fascia which are called medial and lateral
intermuscular septa and are attached to the humerus.
Muscles of the anterior surface are divided into two superficial
(biceps muscle of arm) and deep (coracobrachial and brachial muscles).
Posterior compartment of the arm contains the triceps muscle.
The humerus.
Neurovascular fascicle of the arm anterior surface consists of
brachial vessels and median nerve which pass in medial bicipital
groove. In the upper part of the arm the nerve is located laterally
to the artery; in middle of the arm it crosses the artery in the front;
in lower part it has medial position according to the artery. Median
nerve doesn’t give branches to the arm. Branches of the brachial
artery: muscular branches; deep brachial artery (arises in upper third
and accompanies radial nerve), superior ulnar collateral artery
(arises on border between upper and middle third of the arm and
accompanies ulnar nerve), inferior ulnar collateral artery (arises in
lower third of arm).
The ulnar nerve runs upon the medial side of the brachial artery up
to the border between middle and lower third of the arm where it
pierces medial intermuscular septum and enters posterior compartment
of the arm. At the elbow it passes behind the medial epicondyle where it
can be palpated with finger.
Musculocutaneous nerve runs between the biceps and brachial
muscles and supplies muscles of the arm anterior surface. It ends by
piercing deep fascia 2 cm above the bend of forearm and continues below
the elbow as lateral cutaneous nerve of the forearm.
Neurovascular fascicle of the posterior surface of the arm consists
of deep brachial vessels and radial nerve which pass in the
humeromuscular canal (between radial (spiral) groove of humerus and
triceps muscle of arm). In the lower third radial nerve pierces lateral
intermuscular septum and enters anterior compartment of the arm and
lies between brachial and brachioradial muscles. Deep brachial artery in
canal is divided into radial collateral and middle collateral arteries
which take part in anastomosis around the elbow joint. Fracture of the
humerus through this canal can be accompanied by injury of the deep
brachial artery with bleeding and injury of radial nerve which is
manifested by drop hand.
The cubital region
Borders: upper – circular line which is drawn 4 cm above the
epicondyles of the humerus; lower – circular line which is drawn 4 cm
above the epicondyles of the humerus. Cubital region is divided by the
plane which passes through the epicondyles into anterior (cubital fossa)
and posterior regions.
The anterior cubital region
The skin is thin, flexible.
The subcutaneous fat is divided into two layers by superficial
fascia. Medial and lateral cutaneus nerves of forearm; cephalic, basilic
and median cubital veins are located in deep layer of subcutaneous fat.
These veins form various anastomoses and are used for puncture and
catheterization for diagnostics or treatment.
The deep fascia covers three groups of muscles (external, middle
and internal) and gives two intermuscular septa (medial and lateral).
Muscles of the external group: brachioradial and supinator
muscles. Muscles of the internal group (from the outside inwards):
round pronator muscle, radial flexor muscle of the wrist, long palmar
muscle, ulnar flexor muscle of the wrist, superficial flexor muscle of
fingers. Muscles of the meddle group: biceps muscle of the arm and its
tendon and the brachial muscle.
Between brachioradial and round pronator muscles cubital fossa
is located. Medial neurovascular fascicle (brachial vessels and median
nerve) passes here in the anterior medial cubital groove – between the
medial and middle groups of muscles. In lower part of the cubital fossa
the brachial artery is divided into radial and ulnar arteries. The radial
artery passes in the groove between brachioradial and round pronator
muscles; the ulnar artery goes into the hole between superficial and
deep flexor muscles of fingers. Median nerve leaves cubital fossa by
passing between two heads of the round pronator muscle.
The lateral neurovascular fascicle (radial nerve andradial
collateral arteries) passes in the anterior lateral cubital groove –
between the lateral group of muscles and tendon of biceps muscle of
the arm. Radial nerve is divided into superficial (goes dawnwards in
direction to radial groove of forearm) and deep (penetrates supinator
muscle and goes to posterior surface of forearm) branches at the level
of head of the radius.
Posterior cubital region
The skin is thick, flexible.
The subcutaneous fat contains subcutaneous bursa of olecranon at
the level of elbow joint, branches of cephalic and basilic veins,
articular network of the elbow, posterior cutaneous nerves of the arm
(the branches of radial nerve), medial cutaneous nerve of the arm
(branch of medial fascicle of the brachial plexus).
The superficial fascia is thin, not evident.
The deep fascia is thick; grows together with tendon of the triceps
muscle, olecranon and epicondyles of humerus.
Medial groove is located between medial epicondyle of humerus
and olecranon and contains ulnar nerve and superior ulnar collateral
artery. Due to superficial location of the ulnar nerve (under deep fascia)
different injuries (contusion, compression, luxation, etc.) can be often
observed.
The elbow joint.
The elbow joint is formed by capitellum and trochlea of the
humerus, head of the radius and trochlear notch of the ulna. Thus elbow
joint or cubital articulation consists of humeroradial, humeroulnar and
superior radioulnar joints.
The articular capsule covers all the three joints. On the humerus it is
attached over the edge of radial, coronoid and olecranon fossae and
below epicondyles; on ulna – to margin of trochlear notch and radial
incisure; on radius – to its neck.
Ligaments: ulnar and radial collateral ligaments, annular ligament of
the radius.
Applied anatomy: distensions and dislocations in the posterior
direction occur due to lack of muscles and thin deep fascia.
Ulnar arterial network (articular network of the elbow) is formed
by the brachial artery branches (superior and inferior ulnar collateral
arteries), deep brachial artery (readial and medial collateral arteries),
radial artery (radial recurrent artery), ulnar artery (anterior and
posterior branches of recurrent ulnar artery) and the posterior
interosseous artery (recurrent interosseous artery).
Region of the forearm
Borders: upper – the line, which is drawn 2 cm lower than
epicondyles of the humerus; lower – the line, which is drawn through
styloid processes of the ulna and radii.
Anterior surface of the forearm
Skin is thin and flexible.
Subcutaneous fat is individually developed, contains cephalic vein
which is accompanied by the lateral cutaneous nerve of the forearm,
basilic vein which is accompanied by the medial cutaneous nerve of the
forearm and the median vein of the forearm.
The superficial fascia is thin and friable.
The deep (antebrachial) fascia is connected with the ulna and
divides the forearm into anterior, posterior and lateral compartments. In
anterior compartment flexors and pronators are situated, in posterior
compartment there are extensors and supinators, in lateral there are
brachioradialis and radial extensors of the wrist.
Muscles of the forearm anterior surface may be divided into four
layers:
the first layer includes the brachioradial muscle, round pronator,
radial flexor muscle of wrist, long palmar muscle, ulnar flexor
muscle of wrist;
the second layer includes the superficial flexor muscle of the
fingers;
the third layer includes the thumb long flexor muscle and deep
flexor muscle of the fingers;
the fourth layer includes the quadrate pronator muscle (in the
lower third of the forearm).
Pirogov-Paron fat space is located between the muscles of the third
and fourth layers. Superiorly space extends up to the origin of the deep
flexor muscle of the fingers. Inferiorly it extends up to the flexor
retinaculum and communicates with the midpalmar space. In case of
purulent inflamation of the midpalmar space or tendobursitis pus can go
into Pirogov-Paron fat space.
The ulna and radii connect with each other by interosseus
membrane.
Vessels and nerves are presented by four fascicles: lateral, medial,
superficial median and deep median.
The lateral neurovascular fascicle is located between the
brachioradial muscle and radial flexor muscle of the wrist in radial
groove. It contains the radial artery and veins and superficial branch of
the radial nerve (nerve has lateral position in this groove). Artery leaves
forearm by entering anatomical snuff box; nerve goes to the posterior
surface under the tendon of the brachioradial muscle on border between
the middle and lower third of the forearm.
The medial neurovascular fascicle (ulnar artery, two arteries and
nerve) is located between the wrist ulnar flexor muscle and superficial
flexor muscle of the fingers in the ulnar groove. Nerve has medial
position according to the artery.
The superficial median neurovascular fascicle contains the
median nerve and median artery (branch of the anterior interosseous
artery). In the upper third of the forearm the median nerve passes
between two heads of the round pronator, in the middle third – between
the superficial and deep flexor muscles of the fingers, in the lower third
– between the tendons of the radial flexor muscle of the wrist and
superficial flexor muscle of the fingers covered with the long palmar
muscle.
The deep median neurovascular fascicle (anterior interosseous
artery, veins and nerve) is located on the surface of interosseus
membrane between the deep flexor muscle of the fingers and long
flexor muscle of the thumb.
Features of topography in different parts of the forearm:
neurovascular fascicles in the upper and middle third of the
forearm are covered with muscles, in the lower third they have
superficial position and are covered by the deep fascia;
the radial artery is accompanied by the superficial branch of the
radial nerve in the upper and middle third of forearm, in lower
third there is only radial artery in the radial groove;
the ulnar artery is accompanied by ulnar nerve only in the middle
and lower third of the forearm.
Associated injuries of superficial veins and nerves which pass in
subcutaneous fat, tendons and basic neurovascular fascicles which pass
in grooves can be observed in case of cross incised wounds in lower
third of the forearm. Surgical treatment of such injuries often requires
vascular, nerve and tendon sutures and in view of the aforesaid involves
difficulties.
Posterior surface of the forearm
The skin is thicker than in the anterior surface of the forearm and is
covered by hair.
The subcutaneous fat contains dorsal branches of basilic and
cephalic veins and posterior cutaneous nerve of the forearm (branch of
the radial nerve).
The superficial fascia is thin, friable.
The deep fascia is dense, connected with ulna.
The muscles can be divided into two layers:
superficial layer (from the outside inwards): the long radial
extensor muscle of the wrist, short radial extensor muscle of
the wrist; extensor muscle of the fingers; extensor muscle of
the little finger; ulnar extensor muscle of the wrist;
deep layer (from the outside inwards): supinator, long
abductor muscle of the thumb, short extensor muscle of the
thumb, long extensor muscle of the thumb, extensor muscle
of the index finger.
The fat space is located between two layers of muscles of the
posterior surface of the forearm (contains neurovascular fascicle –
posterior interosseus artery and veins and deep branch of the radial
nerve). It communicates with Pirogov-Paron fat space through holes in
the interosseous membrane in course of anterior and posterior
interosseous arteries.
Region of the wrist joint
Borders: upper – a horizontal line, which is drawn through the
styloid processes of the ulna and radii; lower – a horizontal line, which
is drawn through the pisiform bone. The wrist is divided into anterior
and posterior surfaces by a vertical line, which is drawn through the
styloid processes.
Anterior surface of the wrist
The skin is thin, mobile, without hair.
The subcutaneous fat is poorly developed. Beginnings of
cephalic, basilic and median veins of forearm, terminal branches of
medial and lateral cutaneous nerves of forearm, palmar branches of
median and ulnar nerves are located there.
The superficial fascia is thin.
The deep fascia becomes thicker and forms the flexor
retinaculum. Under the flexor retinaculum three canals are located:
ulnar carpal, carpal and radial carpal canals.
The ulnar carpal canal is prolongation of the forearm ulnar
groove and contains ulnar artery, veins and nerve. After leaving the
canal nerve and artery give deep branches and go into the midpalmar
space (pus can go through the ulnar carpal canal from the midpalmar
space into Pirogov-Paron fat space).
The carpal canal contains the median nerve and nine tendons of
flexor muscles of the fingers (4 – of superficial flexor muscle of
fingers, 4 – of deep flexor muscle of fingers and tendon of long flexor
muscle of thumb). Tendons through this canal pass in the vaginal
synovial membrane (bursas).
The radial synovial bursa contains tendon of long flexor muscle
of thumb; superiorly it goes till Pirogov-Paron fat space, inferiorly it
extends up to base of the distal phalanx of the thumb.
The ulnar synovial bursa contains tendons of the superficial and
deep flexor muscles of the fingers. Superiorly it goes till Pirogov-Paron
fat space. Inferiorly it passes along the little finger tendons up to the base
of the distal phalanx; in the midpalmar space this bursa goes up to the
middle of metacarpal bones shafts.
In some cases the radial and ulnar synovial bursas communicate
with each other at the level of the carpal canal. Therefore in case of
tendovaginitis suppurative process can pass from one bursa into another
(cross or U-shaped phlegmon). In proximal direction pus can break
radial and ulnar bursas and go into Pirogov-Paron fat space.
Inflammation of tendons of the fingers flexor muscles or thickening
of flexor retinaculum can lead to compression of the median nerve and
its vascular supply – carpal tunnel syndrome. This syndrom can occur in
case of professional overtension of fingers and the wrist (gymnasts,
gardeners, builders), arthrosis of the wrist, tumors of the carpal canal,
etc.
The radial carpal canal contains the tendon of radial flexor
muscle of the wrist which is surrounded by the synovial sheath.
Posterior surface of the wrist
The skin is thin, mobile, with hair.
The subcutaneous fat is poorly developed. Beginnings of
cephalic, basilic and median veins of the forearm, terminal branches of
the posterior cutaneous nerve of the forearm, skin branches of the
radial and ulnar nerves are located there.
The superficial fascia is thin.
The deep fascia becomes thicker and forms extensor retinaculum.
Under extensor retinaculum six canals are located where tendons of
extensor muscles pass surrounded by the synovial sheaths (from lateral
to medial side):
I – tendon of the long abductor muscle of the thumb and short
extensor muscle of the thumb;
II – tendons of the long and short radial extensor muscles of the
wrist;
III – tendon of the long extensor muscle of the thumb;
IV – tendons of the extensor muscle of fingers and extensor
muscle of the index finger;
V – tendon of the extensor muscle of the little finger;
VI – tendon of the ulnar extensor muscles of the wrist.
Radial artery passes into the hand dorsum through «anatomical
snuffbox» which is bounded from the lateral side by tendons of the long
abductor muscle of the thumb and short extensor muscle of the thumb,
from medial side it is bounded by the tendon of the thumb long extensor
muscle. There it gives dorsal branch which takes part in formation of
the dorsal carpal network.
Region of the hand
Borders: upper – a horizontal line, which is drawn through the
pisiform bone; lower – the palmar digital fold. The palmar and dorsal
areas of the hand are distinguished.
The palmar surface of the hand
The skin is thick, immobile because of its firm attachment to
palmar aponeurosis. It contains big amount of sudoriferous glands and
lack of hair.
Subcutaneous fat is pierced by fibrous intersections which pass
from the skin to palmar aponeurosis (spreading of purulent processes in
deepth). In case of skin defects wound edges of the palm are gaping and
it is difficult to pull them together with sutures. It contains small veins,
palmar branches of the median and ulnar nerves which supply skin in
regions of the wrist, thenar and hypothenar; branches of the common
palmar digital nerves.
The superficial fascia.
The deep fascia in thenar and hypothenar regions is thin. In
central part the deep fascia is strengthened by the tendon of the long
palmar muscle and presented by triangular in shape palmar aponeurosis
apex of which grows together with flexor retinaculum. In distal part
between longitudinal and transverse fascicles of palmar aponeurosis
there are commissural openings. They are located opposite to II, III, IV
interdigital spaces and correspond to finger-cushions. The
subcutaneous fat communicates with the supaponeurotic fat space
through these openings. From the lateral and medial margins of the
palmar aponeurosis two vertical septa pass to III and V metacarpal bones
combining with deep palmar fascia. They divide palm into three
compartments.
The lateral palmar space (thenar space) is bounded in front by
the deep fascia, from behind it is bounded by the deep palmar fascia,
from the medial side it is bounded by the lateral septum of aponeurosis,
from the medial side it is closed by attachment of the deep fascia to the
first metacarpal bone.
Muscles of thenar are located in the lateral compartment: the short
abductor muscle of the thumb, opposer muscle of the thumb, short
flexor muscle of the thumb (innervation from the motor branch of the
median nerve) and adductor muscle of the thumb (innervation from the
deep branch of the ulnar nerve). Space also contains tendon of the long
flexor muscle of the thumb with its synovial sheath, superficial and deep
tendons of the flexor muscle of the index finger, first lumbrical muscle,
palmar digital vessels and nerves of the thumb and lateral side of the
index finger.
Medial part of the lateral space is filled with fat which is located
between the lateral septum of aponeurosis and adductor muscle of the
thumb. Thenar fat space can be infected by spreading of infection from
the thumb or index finger and from the radial synovial bursa.
The medial palmar space (hypothenar space) is bounded in front
by the deep fascia which is attached to V metacarpal bone; from behind
it is bounded by V metacarpal bone, from medial side – by the lateral
septum of aponeurosis. Muscles of hypothenar are located in the
medial compartment: the short palmar muscle (in subcutaneous fat);
abductor muscle of the little finger, opposer muscle of the little finger
and short flexor muscle of the little finger. Space also contains digital
nerves and vessels of the lateral side of the little finger. The hypothenar
fat is located between muscles and as the thenar fat space is closed, pus
can’t spread to other regions.
The midpalmar space is bounded in front by palmar aponeurosis,
from sides it is bounded by the lateral and medial septa of aponeurosis,
from behind – by the deep palmar fascia. Space contains superficial and
deep flexor tendons of the 3rd, 4th and 5th fingers; the 2nd, 3rd and 4th
lumbrical muscles; superficial and deep palmar arches; digital nerves and
vessels of the 3rd, 4th and medial sides of the 2nd and 5th fingers.
The superficial palmar arch is formed by connection of the ulnar
artery with the superficial palmar branch of the radial artery. It gives 3-4
common palmar digital arteries which go out from palmar aponeurosis
through commissural openings. They combine with metacarpal arteries
from the deep palmar arch and are divided into proper palmar digital
arteries which supply the 3rd, 4th and medial sides of the 2nd and 5th
fingers.
Four common palmar digital nerves are located under the
superficial palmar arch (3 of them start from the median nerve and the
first one is located in the lateral palmar space, 1 – from the ulnar nerve).
The first branch penetrates into the lateral septum of aponeurosis and
takes part in innervation of muscles of the thenar and skin of the first
finger and lateral side of the index finger. The site where the motor
branches come to the thenar muscles from the median nerve is called
«prohibited area of the hand» and corresponds to the proximal third of
the thenar. Incisions in this zone can lead to impairement of the human
palm basic function – thumb opposition.
The deep palmar arch is located under the tendons of the
superficial and deep flexor muscles of the fingers. It is formed by radial
artery deep palmar branch of the ulnar artery and gives three palmar
metacarpal arteries. Deep branch of the ulnar artery is accompanied by
deep branch of ulnar nerve.
There are two layers of fat in midpalmar space. Superficial
(subaponeurotic) palmar fat space is located between palmar
aponeurosis and tendons of superficial and deep flexor muscles of
fingers. It communicates with subcutaneous fat through commissural
openings, with subtendinous palmar fat space along metacarpal
arteries, with Pirogov-Paron fat space through the carpal canal.
The deep (subtendinous) palmar fat space is located between the
tendons of the superficial and deep flexor muscles of the fingers and the
deep palmar fascia which covers the lumbrical muscles. It
communicates with Pirogov-Paron fat space through the carpal canal,
with fat of the hand dorsal surface along the lumbrical muscles.
The dorsal surface of the hand
The skin is thin, flexible and covered by hair, contains sudoriferous
and sebaceous glands.
The subcutaneous fat is friable, not evident. It contains the dorsal
venous arch and lymphatic vessels. Due to the fact that the palm skin is
dense and firmly fixed to the palmar aponeurosis venous and lymphatic
outflow goes to the hand dorsal surface (in case of palm purulent
inflamation there is edema of the hand dorsum).
The superficial fascia is thin.
Proper (deep) fascia.
The subaponeurotic dorsal space contains tendons of the extensor
muscle of the fingers, extensor muscle of the index finger, extensor
muscle of the little finger, branches of the radial artery, ulnar nerve and
superficial branch of the radial nerve. It communicates with the fat space
of the forearm posteriot surface through canals under the extensor
retinaculum.
The dorsal interosseous muscles and metacarpal bones which are
covered by the deep dorsal fascia.
Region of the fingers
Borders of the fingers on the palm correspond to the distal
transverse skin fold, on the dorsal surface – to the heads of the
metacarpal bones.
The skin of palmar surface is thick, not flexible.
The subcutaneous fat is well developed and has cellular structure
due to the fibrous septa which pass from the skin to the periosteum on
the distal phalanges and to the fibrous sheaths of the tendons of fingers
flexor muscles– on proximal and middle phalanges. That is why
infectious process of the subcutaneous fat penetrates in deapth and can
cause osteomyelitis of the phalanges. The palmar and dorsal proper
digital arteries and nerves are located in the subcutaneous fat along the
fingers lateral surfaces.
The palmar digital arteries form the arterial network on the distal
phalanges, dorsal artery reaches only the distal interphalangeal joint.
Veins are more developed on the fingers dorsum where they form a
venous network.
The palmar digital nerves innerve palmar surface of the proximal
and medial phalanges, palmar and dorsal surfaces of the distal phalanges
(I, II, III and medial surface of IV finger – from the median nerve; V
and lateral surface of IV finger – from the ulnar nerve). Dorsal surface
of proximal and medial phalanges is innerved by the dorsal digital nerves
(I, II and half of III finger – from the superficial branch of the radial
nerve; IV, V and half of III finger – from the ulnar nerve).
Lymphatic vessels go also along the finger sides and pass to the
dorsal surface in the region of metacarpophalangeal articulations.
Fibrous sheaths of fingers are located on the palmar surface and
made by deep fascia of the fingers. They contain tendons of long flexor
muscles of fingers and consist of two leafs. Parietal (peritendineum) is
fixed to the walls of osteofascial tunnel; visceral (epitendineum) – covers
the tendons. Place where parietal layer of the fibrous sheath passes into
the visceral one is called mesotendineum (vessels that supply the tendons
of the long flexor muscles of the fingers go through it).
Tendons of the superficial flexor muscles of the fingers split into
medial and lateral slips which are attached to sides of the middle
phalanges of four fingers. Tendons of the deep flexor muscles of the
fingers perforate the tendon of the superficial flexor muscles of the
fingers and are attached to the base of distal phalanx of the medial four
fingers. The tendon of the thumb flexor muscle the is attached to the
thumb distal phalanx.
The synovial sheaths of II, III and IV fingers are independent and
terminate proximally at the level of heads of metacarpal bones. That is
why in case of purulent tendovaginitis necrosis of the tendons may occur
due to occlusion of the vessels by tension of the synovial sheaths which
leads to early opening of the synovial sheaths. The synovial sheath of the
little finger combines in proximal direction with the ulnar bursa, synovial
sheath of the thumb combines with the radial bursa.
The tendon of the extensor muscle of the fingers is divided near
the proximal interphalangeal joint into the central and two collateral
slips. Central slip is attached to the base of middle phalanx, two
collateral slips are attached to the dorsum of the distal phalanx base.
Phalanges and interphalangeal joints.
3. Projections of vessels and nerves of the lower limb.
PROJECTIONS OF MAIN NEUROVASCULAR BUNDLES OF LOWER
EXTREMITIES
GLUTEAL
REGION
Superior gluteal vessels and nerve
Mark the following points:
1. point at the
posterior superior iliac spine;
2. point at the apex of the greater trochanter.
The superior gluteal artery enters the gluteal region at the
junction of the upper and middle thirds of the line joining two points.
Inferior gluteal vessels and nerve
Mark the following points:
1. first point –
posterior superior iliac spine;
2. second point – ischial tuberosity.
Then mark a third point 2.5 cm lateral to the midpoint of the
line joining (1) and (2). The sciatic nerve enters the gluteal region at this
point. The inferior gluteal artery appears just medial to the entry of the
sciatic nerve. Posterior cutaneous nerve of thigh, internal pudendal vessels
and nerve are located in this point.
FEMORAL
REGION
Femoral artery
It corresponds to the upper two thirds of a line joining the
following two points:
1. midinguinal point –
a point midway between the anterior superior iliac spine and the pubic
symphysis;
2. adductor tubercle.
It lies at the lower end of the cord-like tendon of the
adductor magnus. The tendon can be felt in a shallow groove
just behind the prominence of the vastus medialis when the thigh is
semi-flexed, abducted and laterally rotated.
The upper one third of the line represents the upper half of
the artery lying in the femoral triangle. The middle one third of the line
represents the lower half of the artery lying in the adductor canal. The lower
one third of the line represents the descending genicular and saphenous
branches of the artery.
Femoral vein
Its marking is same as that of the femoral artery, except
that the upper point is taken 1 cm medial to the rmdinguinal point, and the
lower point 1 cm lateral to the adductor tubercle. The vein is medial to the
artery at the upper end, posterior to it in the middle, and lateral to it at
the lower end.
Femoral nerve
It is marked by joining the following two points:
1. point 1.2 cm lateral
to the midinguinal point;
2. point 2.5 cm vertically below the first point.
Sciatic nerve
It is marked by joining the following points:
1. point 2.5 cm lateral
to the midpoint between the posterior superior iliac spine and the ischial
tuberosity;
2. point just medial to the midpoint between the ischial
tuberosity and the greater trochanter;
3. point in the midline of the back of the thigh at the
junction of its upper two thirds and lower one third, i.e. at the apex of the
popliteal fossa.
Profunda femoris artery
The profunda artery is marked by joining the following two
points on the femoral artery:
1. point 3.5 cm below
the midinguinal point;
2. point 10 cm below the midinguinal point.
The artery is slightly convex laterally in its' upper part.
Great saphenous vein
It can be marked by joining the following points:
1. point at posterior
edge of medial condyle;
2. point just below the centre of the saphenous opening.
Lateral cutaneous nerve of thigh
It is marked medially and lower than anterior superior iliac
spine.
Posterior cutaneous nerve of thigh
The point of entrance in subcutaneous fat of thigh is marked
at the middle of gluteal fold.
GENUS
REGION
Popliteal vessels
It is marked by joining the following points:
1. point at the
junction of the middle and lower thirds of the thigh, 2.5 cm medial to the
midline on the back of the limb;
2. point on the midline
of the back of the knee;
3. point on the midline of the back of leg at the level of
the tibial tuberosity.
Tibial nerve
Mark the following points:
1. point in the midline
of the back of the thigh at the junction of its upper two thirds and lower one
third, i.e. at the apex of the popliteal fossa;
2. point midway between the medial maileolus and tendo
calcaneus.
The line joining (1) and (2) represents the tibial nerve in
the popliteal fossa.
Common peroneal nerve
It is marked by joining the following two points:
1. point at the upper
angle of the popliteal fossa;
2. point on the back of the neck of the fibula.
At the lower end the nerve turns forwards and ends deep to
the upper fibres of the peroneus longus.
Great saphenous vein and saphenous nerve
These structures are marked at the point located behind
medial condyle of femur.
Small saphenous vein
It is marked by joining the following two points:
1. point at the lower
angle of the popliteal fossa;
2. point at the centre of the popliteal fossa.
REGION OF
LEG
Anterior tibial artery
It is marked by joining the following two points:
1. point 2.5 cm below the medial side of the head of
the
fibula;
2. point midway between the two malleoli.
The artery passes downwards and slightly medially.
Deep peroneal nerve
It is marked by joining the following two points:
1. point on the lateral
aspect of the neck of the fibula;
2. point in front of the ankle, midway between the two
malleoli.
The nerve lies lateral to the anterior tibial artery in its
upper and lower thirds, but anterior to the artery in its middle third.
Superficial peroneal nerve
It is marked by joining the following two points.
1. point on the lateral
aspect of the neck of the fibula;
2. point on the anterior border of the peroneus longus at the
junction of the upper two thirds and lower one third of the leg.
Posterior tibial artery and tibial nerve
It is marked by joining the following two points:
1. point on the midline
of the back of the calf at the level of the tibial tuberosity;
2. point midway between the medial malleolus and the tendo
calcaneus.
Peroneal artery
It is marked by joining the following two points:
1. point at the lower
angle of the popliteal fossa;
2. point at lateral malleolus.
The artery is projected in medial and lower third of this
line.
Small saphenous vein
It can be marked by joining the following points:
1. point just lateral
to the tendo calcaneus above the lateral maileolus;
2. point at the centre of the popliteal fossa.
Great saphenous vein and saphenous nerve
It can be marked by joining the following points:
1. point on the anterior surface of the medial maileolus;
2. point on the posterior surface of medial condyle of femur.
REGION OF
FOOT
Dorsalis pedis artery
It is marked by joining the following two points:
1. point midway between
the two malleoli;
2. point at the proximal end of the first intermetatarsal
space.
Deep peroneal nerve
It is marked at the level of first intermetatarsal space.
Division of posterior tibial artery and tibial nerve
It is marked at the middle of distance between posterior edge
of medial malleolus and calcaneal tuber.
Medial plantar artery and nerve
They are marked by joining the following two points:
1. point midway between
the medial malleolus and the prominence of the heel;
2. point on the navicular bone which lies midway between the
back of the heel and the root of the big toe.
The artery runs in the direction of the first interdigital
cleft.
Lateral plantar artery and nerve
They are marked by joining the following two points:
1. point midway between
the medial malleolus and the prominence of the heel;
2. point 2.5 cm medial to the tuberosity of the fifth
metatarsal bone.
Plantar arch
It is marked joining the following two points:
1. point 2.5 cm medial
to the tuberosity of the fifth metatarsal bone;
2. point at the
proximal end of (he first intermetatarsal space, 2.5 cm distal to the
tuberosity of the navicular bone.
The arch is slightly curved with its convexity directed
fowards.
MISCELLANEOUS
STRUCTURES
Saphenous opening
Its centre lies 4 cm below and 4 cm lateral to the pubic
tubercle. It is about 2.5 cm long and 2 cm broad, with its long axis directed
downwards and laterally.
Femoral ring
It is represented by a horizontal line half inch long over
the inguinal ligament half an inch medial to the midiguinal point.
PROJECTION
OF JOINTS OF LOWER LIMB
Hip joint
In front joint space is projected on a line which is drawn
from anterior superior iliac spine to pubic tubercle. Perpendicular line which
is drawn through the middle of it divides head of femur into two equal parts.
From behind joint space is marked on a line which is drawn
from posterior superior iliac spine to the base of greater trochanter. In front
joint space is marked by transverse sulci on each side of patella ligament
between condyles of femur and tibia.
From behind joint space corresponds to skin fold in popliteal
fossa.
Ankle joint
Line of joint space is marked on 2.5 cm higher than the top
of lateral malleolus.
Talocalcaneonavicular articulation
Line of joint space is in form of “S”. Medially it is marked
behind the tuberosity of navicular bone, lateraly – 1.5 cm behind than
tuberosity of fifth metatarsal bone.
Tarsometatarsal articulations
Joint space is marked from tuberosity of fifth metatarsal
bone to the middle of medial edge of foot in the form of anteriorly convex
line.
4. Topographic anatomy of lower limb (gluteal region; regions of thigh, popliteal fossa, leg, foot; hip, knee, ankle, talocalcaneonavicular, tarsometatarsal joints; canals, fat spaces, ways of pus distribution).
TOPOGRAPHIC ANATOMY OF THE LOWER LIMB
The lower limb is bounded in front by the inguinal fold, from
external side – by the iliac crest, from behind – by the line, which is
drawn between the anterior superior iliac spine and coccygeal bone, from
internal side – by the perineofemoral fold. The gluteal region, anterior
and posterior regions of the thigh, anterior and posterior regions of the
knee, anterior and posterior regions of leg, anterior, posterior, lateral and
medial regions of the ankle joint, regions of the dorsum and foot sole,
regions of fingers are distinguished in the lower extremity.
The gluteal region
Borders: upper – the iliac crest, lower – the gluteal fold, medial –
the median sacral and coccygeal line, lateral – the line, which is drawn
from the anterior superior iliac spine to the greater trochanter.
The skin is thick, contains a great amount of sudoriferous and
sebaceous glands. It is connected with the gluteal fascia by fibrous
intersections.
The subcutaneous fat is evident, consists two layers (deep layer
goes into the fat of the lumbar region and is called lumbogluteal adipose
tissue). It contains superior, medial and inferior clunium nerves. Blood
supply of the skin and subcutaneous tissue is derived from the
perforating branches of the superior and inferior gluteal arteries.
The superficial fascia is thin.
Deep (gluteal) fascia is thick and dense. It is divided into two
layers and encloses gluteus maximus muscle. That is why after
intramuscular injections local infiltrates may occur inside of the muscle
that leads to tension of tissues and sharp pain.
The muscles lie in three layers. The superficial layer is presented by
the gluteus maximus muscle; the middle layer is presented by gluteus
medius, piriformis, superior and inferior gemelli, obturator internus
muscles and quadrate muscle of the thigh; the deep layer is presented by
the gluteus minimus and obturator externus muscles. Two layers of fat
are located between the layers of muscles.
The piriformis muscle goes through the greater sciatic opening and
divides it into suprapiriformis and infrapiriformis foramens. Superior
gluteal neurovascular fascicle passes through the suprapiriformis
foramen. The pudendal nerve and the internal pudendal vessels, inferior
gluteal nerve, posterior cutaneous nerve of the thigh, inferior gluteal
vessels and sciatic nerve pass (from the medial to lateral part) through
the infrapiriformis foramen.
The superior gluteal artery is short and fixed by fascia to the bone.
So in case of injuries it gapes and contracts and goes into the lateral
pelvic fat space. Because of large muscle layer it is very difficult to stop
bleeding from the artery and surgeon has to ligate the posterior trunk of
the internal iliac artery.
The pudendal nerve and internal pudendal vessels leave gluteal
region by passing into the lesser sciatic foramen through which they
enter the ischiorectal fossa.
Greatest amount of fat in the gluteal region is located between the
first and second layers of muscles. It communicates with:
o lateral fat space of the pelvis through the infrapiriformis
foramen;
o fat space of the ischiorectal fossa through the lesser sciatic
foramen;
o fat space of the back of thigh along the sciatic nerve;
o fat space of the medial side of thigh along the anastomosis
between the inferior gluteal and obturator arteries.
Hip joint is formed by the head of the femur and acetabulum of
the hip bone.
The articular capsule is attached to the edge of acetabulum
(acetabular labrum is inside of joint’s cavity); on the neck of the femur
it is attached to the intertrochanteric line in front and 1 cm medially to
the intertrochanteric crest from behind (all anterior surface and major
part of posterior surface of the neck is inside of the joint cavity).
The ligaments of the hip joint are divided into intraarticular and
extraarticular parts. The intraarticular ligament is presented by round
ligament of the femur. It transmits arteries to the head of the femur
(from acetabular branches of the obturator and medial circumflex
femoral arteries). The extraarticular ligaments form the fibrous ring of
the articular capsule and include the iliofemoral ligament which lies
anteriorly and is one of the strongest ligaments in the body, the
pubofemoral ligament which supports the joint inferomedially and
ischiofemoral ligament which covers joint posteriorly.
Weak places of the articular capsule are located between the
extraarticular ligaments; pus can move to other regions through these
sites in case of coxitis.
The femoral region
Borders: upper anterior – the inguinal fold, upper posterior – the
gluteal fold; inferior – the line which is drawn 4 cm above the patella.
The frontal plane which is drawn through epicondyles of the femur
divides the femoral region into anterior and posterior surfaces.
Anterior surface of the thigh
The skin is thin and flexible.
The subcutaneous fat is divided into two layers by the superficial
fascia. It contains cutaneous nerves, cutaneous arteries, great saphenous
vein and superficial inguinal lymph nodes. The skin nerves begin from
the lumbar plexus or its branches:
- the femoral branch of the genitofemoral nerve goes to the thigh
together with the femoral artery and supplies the femoral triangle
skin;
- the lateral cutaneous nerve of the thigh supplies the skin of the
thigh anterolateral side;
- the intermediate cutaneous nerve of the thigh (branch of the
anterior division of the femoral nerve) supplies skin of the thigh
anterior surface from the sartorius muscle to the knee.
- the medial cutaneous nerve of the thigh (branch of the anterior
division of the femoral nerve) supplies the skin on medial side of
the lower two thirds of the thigh and upper one third of the leg;
- the saphenous nerve (branch of the posterior division of the
femoral nerve) supplies the skin of medial side of the leg and the
foot up to a big toe.
- the cutaneous branch of the obturator nerve supplies the skin of
lower third of the thigh medial side together with the medial
cutaneous nerve;
- ilioinguinal nerve supplies the skin at the root of the penis (or over
the mons pubis in female), anterior third of the scrotum (or labium
majus) and superomedial part of the thigh.
Superficial branches of the femoral artery (superficial
epigastric, external pudendal and superficial circumflex iliac arteries)
and superficial veins (great saphenous vein) pass through the
saphenous opening perforating cribriform fascia.
The deep fascia of the thigh (lata fascia) is dense. It is located in
the upper third of the anterior surface of the thigh and consists of two
layers – superficial (it is attached to the inguinal ligament and forms
saphenous opening which is covered by the cribriform fascia) and deep
(covers the pectineal and greater psoas muscles) between which femoral
vessels and deep inguinal lymph nodes are located. In the lateral part of
the thigh the lata fascia forms the iliotibial tract together with the tensor
muscle of the fascia lata. It also gives three intermuscular septa which
divide muscles of the thigh into three compartments: anterior (contains
extensors of the eg), medial (adductor muscles) and posterior (flrxors
of the leg).
Muscles of anterior (quadriceps muscle of the thigh and tailor's
(sartorius) muscle) and medial compartments (great, long and short
adductor muscles and gracilis muscle).
The femoral bone.
Muscular and vascular lacunes
At the upper part of the thigh there is space which is bounded in
front by the inguinal ligament, from behind and laterally – by the pubic
and iliac bones. Dense connective tissue septa (iliopectineal arch) which
passes from the inguinal ligament to the iliac bone, divides this space
into two parts – muscular and vascular lacuna.
The lateral part of this space is called muscular lacuna which is
bounded in front by the inguinal ligament, from medial side – by the
iliopectineal arch, from behind and laterally – by the iliac bone. The
iliopsoas muscle, femoral nerve and lateral cutaneous nerve of the thigh
pass through this lacuna.
The vascular lacuna has medial position and it is bounded in
front by the inguinal ligament, from behind – by the pubic bone and
pectineal ligament, from lateral side – by the iliopectineal arch, from
the medial side – by the lacunar ligament. Contents:
The femoral artery, vein and femoral branch of the genitofemoral
nerve pass through this lacuna (femoral vein has a medial position,
femoral vein passes laterally from the vein). Between the lacunar
ligament and femoral vein there is a (femoral ring) which is filled by
fat and Rosenmullar-Pirogov lymph node. The femoral ring is covered
by the endoabdominal fascia from the direction of the abdominal cavity
and the femoral fossa at this site is formed (weak place for femoral
hernias).
The femoral canal
The femoral canal naturaly doesn’t exist. It is formed during
formation of a femoral hernia (in case of going out of the parietal
peritoneum with internal organs through the femoral fossa between the
superficial and deep layers of the lata fascia and then under the skin of
the thigh through the saphenous opening).
Rings of the femoral canal:
1. The internal (deep) ring corresponds to the femoral opening
which is bounded:
in front – by the inguinal ligament;
from back – by the pectineal ligament;
medialy – by the lacunar ligament;
lateraly – by the femoral vein.
2. Superficial ring is a saphenous opening (hiatus saphenus)
covered by the cribriform fascia.
Walls of the femoral canal:
1. anterior – the superficial layer of the femoral (lata) fascia;
2. posterior – the deep layer of the femoral fascia;
3. medial – the femoral vein.
Length of the femoral canal is about 1-2 cm.
The femoral triangle
Borders: superior – the inguinal ligament, lateral – the sartorius
(tailor's) muscle, medial – the long adductor muscle.
Floor of the triangle is formed by the pectineus iliopsoas muscles.
Edges of these muscles form the iliopectineal groove. The femoral
vessels and saphenous nerve pass in this groove and are covered by the
sartorius muscle. Continuation of the iliopectineal groove is the anterior
groove of the thigh.
Contents of the femoral triangle is following:
1. The femoral artery and its branches. It gives six branches: three
superficial and three deep ones. Superficial branches: superficial
external pudendal, superficial epigastric and superficial circumflex
iliac arteries. Deep branches: deep femoral, deep external pudendal
arteries and muscular branches. Deep femoral artery is the largest
branch of the femoral artery and it gives medial and lateral
circumflex femoral arteries.
2. The femoral vein and its branches. The vein is medial to the
femoral artery at the triangle base, but at the apex it has
posteromedial positon to the artery. Branches of the femoral vein
are: the great saphenous vein and veins which correspond to the
branches of the femoral artery.
3. The femoral nerve lies laterally to the femoral artery at the base of
the triangle. From the middle third of the femoral triangle the artery
is accompanied by the largest branch of the femoral nerve –
saphenous nerve (it has anterolateral position). 2 cm below the
inguinal ligament the femoral nerve is divided into muscular and
cutaneous branches.
4. The deep inguinal lymph nodes are about 4 to 5 in number and lie
medially to the upper part of the femoral vein. The most proximal
node of this group (Rosenmullar-Pirogov lymph node) lies in the
femoral canal. These nodes receive lymph from the superficial
inguinal, popliteal nodes, glans penis or clitoris and deep
lymphatics of the lower limb accompanying the femoral vessels.
The adductor canal is prolongation of the anterior groove of the
thigh. It is also called a subsartorial canal or Hunter's canal. The canal is
triangular on cross section, and has anterior, posterior and medial walls.
Walls: the anterior wall is formed by the medial vastus muscle,
posterior – by the great adductor muscle (in the upper third by the long
adductor muscle), medial wall – by the vastoadductorial lamina (strong
fibrous membrane joining the anterior and posterior walls). In the front
medially adductor canal is covered by sartorius muscle.
Contents: femoral vessels and saphenous nerve. The nerve lies on
the anterior wall of the femoral artery, the vein lies behind the artery.
Openings: one inlet (or entry hole) and two exit holes. The
femoral vessels and the saphenous nerve go into adductor canal through
the inlet. The saphenous nerve and descending artery of the knee leave
the canal throug the first exit hole which is located in the
vastoadductorial lamina. Femoral vessels leave the canal through the
second exit hole which is located under the tendon of the great adductor
muscle and go in the popliteal fossa.
The obturator canal extends from the pelvic cavity to the
anteromedial surface of the thigh. Length is not more than 2 cm,
direction is oblique, coinciding with the direction of the inguinal canal.
The obturator canal is formed by the obturator groove of the pubic bone
horizontal branch, obturator membrane and obturator muscles (internal
and external).
Contents of the obturator canal: the obturator artery, vein and nerve
(the vein is located medially from the artery, the nerve – from behind and
medially).
Posterior surface of the thigh
The skin is thin, flexible. It is supplied by the branches from the
posterior cutaneous nerve of the thigh.
The subcutaneous fat is evident.
The superficial fascia is thin.
The deep fascia.
Muscles of the posterior surface of the thigh are presented by the
semitendinosus, semimembranosus and biceps muscles. In the lower
third of the thigh separtion of muscles is observed and semitendinosus,
semimembranosus muscles form the upper medial wall of the popliteal
fossa, biceps muscle of the thigh form upper lateral wall of the
popliteal fossa.
The sciatic nerve and sciatic artery (accompanying artery of the
ischiatic nerve) pass between the muscles. In the upper third of the thigh
near the lower edge of the gluteus maximus muscle this nerve lies
superficially under the lata fascia. In the middle third the sciatic nerve is
covered by long head of the biceps muscle of the thigh. In the lower third
of the thigh nerve passes medially to the long head of the biceps muscle
and is divided into two branches: the tibial nerve and the common
peroneal nerve.
Ways of pus distribution from the fat round sciatic nerve: above –
with fat between the superficial and middle layers of the gluteal region
muscles, below – with fat of the popliteal fossa, through the adductor
canal – with fat of the anterior thigh surface.
The knee joint region
Borders: upper – the circular line which is drawn 4 cm above the
patella; lower – the circular line which is drawn through the tibia
tuberosity. Region of the knee joint is divided into anterior and
posterior surfaces by vertical lines which are drawn through the
posterior edges of the femur condyles.
The posterior surface of the knee joint region represents most
practical interest.
The skin is thin, not flexible.
The subcutaneous fat is moderately developed and has cellular
structure. It contains branches of the posterior cutaneous nerve of the
thigh and trunks of the great saphenous vein and sapheenous nerve.
Thу ыuperficial fascia is well developed and connected with еру
skin by intersections.
The deep fascia (popliteal fascia) is continuation of the lata
fascia. The small saphenous vein lies between the deep fascia layers
upon the midline of the region. It perforates popliteal fascia and goes
into the popliteal vein.
The muscles of the posterior surface of the knee joint region limit
the popliteal fossa. From above and laterally – biceps muscle of thigh,
from above and medially – semitendinosus and semimembranosus
muscles, from below and medially – medial head of gastrocnemius
muscle, from below and laterally – lateral head of gastrocnemius
muscle. The floor of the popliteal fossa is formed by the popliteal
surface of the femur, capsule of the knee joint and the oblique popliteal
ligament, popliteus muscle. The content of the fossa is the neurovascular
fascile (popliteal artery, vein and their branches, tibial nerve and its
branches). The fossa also contains the common peroneal nerve and its
branches, posterior cutaneous nerve of the thigh, genicular branch of the
obturator nerve popliteal lymph nodes, fat. The lateral cutaneous nerve
of the calf (branch of common peroneal nerve) passes in spliting of the
deep fascia which covers the lateral head of the gastrocnemius muscle,
medial cutaneous nerve of the calf (branch of tibial nerve) passes
between heads of the gastrocnemius muscle under deep fascia. Syntopy
of the neurovascular fascicle elements: superficialy and laterally –
tibial nerve, than – popliteal vein, deep and medially – politeal artery
(NeVA).
Common peroneal nerve passes under the edge of the biceps
tendon and is adjacent to the capsule of the knee joint. Then it goes
around the neck of the fibula and enters lateral compartment of the leg
(superior musculoperoneal canal) where divides into superficial and deep
branches. Superficial position of the common peroneal nerve at the level
of the fibula explains that it is susceptible to injuries (can be damaged in
case of fractures of fibula or compressed by plaster cast).
Knee joint.
Ways of pus distribution from the popliteal fossa:
- into fat of the posterior surface of the thigh (along tibial nerve);
- into fat of the anterior surface of the thigh (through the adductor
canal along the femoral vessels);
- into fat of the posterior surface of the leg (along the posterior
tibial artery and tibial nerve);
- into fat of the anterior surface of the leg (along the anterior tibial
artery).
Arterial network forming anastomosis round the knee joint
The superior genicular arteries (lateral and medial) pass from the
politeal artery at the level of upper edge of femur condyles. The
inferior genicular arteries (lateral and medial) pass from the politeal
artery near the lower edge of the popliteal muscle. The medial
genicular artery passes at the level of the knee joint space. In addition
to these arteries the descending artery of the knee (branch of the
femoral artery) and anterior recurrent artery of the tibial bone take part
in formation of the arterial network round the knee joint.
The knee joint
The knee joint is formed by condyles of the femur, condyles of the
tibia and patella. There are two cartilages at the articular surfaces of the
tibia – medial and lateral menisci which are connected by the transverse
ligament of the knee. They deepen the articular surfaces of tibia
condyles (help to make articular surfaces of the femur and tibia more
congruent). Medial meniscus is nearly semicircular (like letter “C”),
lateral – circular (like letter “O”). Joint capsule is fixed to the thickened
external edges of the menisci.
The articular capsule on the femur in front is attached 5cm above
the articular cartilage, from each side – below epicondyles (epiphyseal
line of the femur is located inside the knee joint). In front the capsule is
fixed to edges of the patellar cartilage; on the tibia – to the edge of the
articular cartilage (epiphyseal line is located below the joint capsule).
Ligaments of the knee joint are divided in intraarticular and
extraarticular.
The intraarticular ligaments
Cruciate ligaments are very thick, strong fibrous bands are located
between the femur and the tibia. They are anterior and posterior
according to their attachment to the tibia.
Transverse ligament of the knee connects medial and lateral
menisci.
Meniscofemoral ligaments connect the femur with menisci.
Extraarticular ligaments include patellar ligament, tibial and
fibular collateral ligaments, oblique and arcuate popliteal ligaments.
Weak places
Synovial membrane of the joint capsule forms 9 recesses: in front
and from above – the upper medial, upper lateral and median unpaired
recesses; in front and below – the lower medial and lateral recesses;
behind and from above – the upper medial and upper lateral recesses;
behind and below – the lower medial and lateral recesses. Median
unpaired recess communicates with the synovial patellar bursa. Bursitis
of this bursa can lead to inflammation of the knee joint (gonitis).
Region of the leg
Borders: the upper border is frontal plane, which is drawn through
the tuberosity of the tibia; the lower one is frontal plane, which is drawn
through the malleoli of tibia and fibula.
Anterior surface of the leg
The skin is thin, not flexible, covered by hair.
The subcutaneous fat is poor developed, contains the great
saphenous vein, branches of the saphenous nerve and the small
saphenous vein, superficial peroneal nerve and lymphatic vessels.
The superficial fascia.
The deep fascia is well developed and forms two intermuscular
septa (anterior and posterior) due to what two osteofibrous compartments
(anterior and lateral) are distinguished in the anterior surface of the leg.
The anterior intermuscular septum is located between the extensors
peroneus muscles and forms the lateral border of the anterior
osteofibrous compartment. The medial border of this compartment is
formed by external surface of the tibia, back border – by the interosseous
membrane.
The anterior tibial muscle (medial position), long extensor muscle
of toes (lateral position) and long extensor muscle of the great toe
(between previous two muscles) are located in the anterior
compartment of the leg. The anterior neurovascular fascicle (anterior
tibial vessels and deep peroneal nerve) is located on the interosseous
membrane between the muscles. The deep peroneal nerve is lateral to
the anterior tibial artery in the upper and lower thirds of the leg and
anterior to it in the middle third of the leg.
The lateral osteofibrous compartment is located between the
anterior and posterior intermuscular septa and external surface of the
fibula. Long and short peroneal muscles and the superficial peroneal
nerve are located there. In the upper third of the leg the nerve pierces the
anterior intermuscular septum and passes between the fibula and the long
peroneal muscle in the superior musculoperoneal canal. On the border
between the lower and middle thirds of the leg the superficial peroneal
nerve pierces the deep fascia and goes into the subcutaneous fat.
The tibia, fibula and interosseus membrane.
The posterior surface of the leg
The skin is thin, flexible.
The subcutaneous fat is evident, contains branches of the lateral
and medial cutaneous nerves of the calf, sural and saphenous nerves,
saphenous veins and superficial lymphatic vessels.
The superficial fascia.
The deep fascia takes part in formation of the posterior
osteofibrous compartment which is bounded in front by the tibia, fibula
and interosseous membrane, from the external side it is bounded by the
posterior intermuscular septum and fibula, from the internal side – by the
deep fascia and tibia, from behind – by the deep fascia.
Posterior osteofibrous compartment is divided by deep layer of
the crural fascia into superficial and deep layers. Superficial layer of
the posterior compartment contains the gastrocnemius, salens and
plantar muscles; deep layer contains the long flexor muscle of toes,
long flexor muscle of great toe and posterior tibial muscle.
The posterior neurovascular fascicle of the leg ( the posterior
tibial vessels and the tibial nerve) passes between the superficial and
deep layers of muscles in the cruropopliteal canal. The canal is
bounded in front by the posterior tibial muscle, from behind – by the
deep layer of the crural fascia which covers the salens muscle, from the
medial side – by the long flexor muscle of the toes, from the lateral side
– by the long flexor muscle of the great toe. The canal has one inlet and
three exit holes. The inlet is located between the tendinous arch of the
salens muscle and popliteal muscle. The popliteal vessels and tibial
nerve enter cruropopliteal canal through this hole. In the initial part of
the canal the popliteal vessels are divided into anterior and posterior
tibial vessels. The first exit hole is located in the interosseus membrane.
The anterior tibial artery passes throug it into the anterior compartment
of the leg. The second exit hole is located in the middle third of the leg
between the long flexor muscle of the great toe and posterior tibial
muscle. The peroneal artery passes throug it into the inferior
musculoperoneal canal (canal is bounded by the long flexor muscle of
the great toe, posterior tibial muscle and fibula). The third exit hole is
located between the middle and lower third of the leg and is bounded
by the medial edge of the salens muscle and the posterior tibial muscle.
The posterior tibial vessels and tibial nerve leave cruropopliteal canal
throug this hole and go to the malleolar canal. Phlegmons from the
cruropopliteal canal can go along the vessels and nerves into the
neighbour regions (popliteal fossa, anterior suraface of leg, foot).
Region of the ankle joint
Borders: horizontal and frontal planes, which are drawn through
the right and left malleoli. Anterior, medial, lateral and posterior
surfaces are distinguished in region of the ankle joint.
Anterior surface of the ankle joint region
The skin is thin, flexible.
The subcutaneous fat is evident; the superficial peroneal nerve,
branches of the great saphenous vein and saphenous nerve pass in it.
The superficial fascia.
The deep fascia is thick and forms the superior and inferior
extensor retinacula. The tendons of the anterior compartment muscles are
covered by the synovial sheaths (from medial to lateral: of the anterior
tibial muscle, long extensor muscle of the great toe, long extensor
muscle of the toes) and the anterior neurovascular fascicle (anterior
tibial artery lies medially to deep peroneal nerve) are located under the
extensor retinacula. Each tendon occupies the separate compartment, the
nerve and artery lie between tendons of the long extensor muscle of the
great toe and long extensor muscle of the toes.
The ankle joint.
The medial surface of the ankle joint region
The skin is thin, flexible.
The subcutaneous fat is evident, contains the saphenous nerve,
great saphenous vein, medial anterior malleolar artery and medial
malleolar branches of the posterior tibial artery (this arteries form medial
malleolar network).
The superficial fascia.
The deep fascia forms flexor retinaculum which is located between
the medial malleolus and heel bone (heel bone and flexor retinaculum
form malleolar canal). The tendon of the posterior tibial muscle, tendon
of the long flexor muscle of the toes, posterior tibial vessels and tibial
nerve, tendon of long flexor muscle of the great toe pass into the
malleolar canal from the medial to lateral side. Each tendon occupies the
separate compartment and is covered by the synovial sheath. Nerve and
artery pass in the common compartment and in the lower part of the
canal are divided into the medial and lateral plantar neurovascular
fascicles.
The ankle joint.
Lateral surface of the ankle joint region
The skin is thin, flexible.
The subcutaneous fat is evident, contains lateral malleolar network
(it is formed by the lateral anterior malleolar artery and lateral malleolar
branches of the peroneal artery), sural nerve and branches of the small
saphenous vein.
The superficial fascia.
The deep fascia forms the superior and inferior peroneal retinacula.
The tendons of long and short peroneal muscles covered by synovial
sheaths pass under them.
The ankle joint.
Posterior surface of the ankle joint region
The skin is thick.
The subcutaneous fat is evident, contains calcaneous network
which is formed by branches of the posterior tibial and peroneal arteries.
The superficial fascia.
The deep fascia forms sheath for calcaneal tendon (Achilles
tendon).
The achilles tendon.
The achilles synovial bursa is located between the calcaneal tendon
and the calcaneal tuber.
The ankle joint
The ankle joint is formed by the lower end of the tibia including
medial malleolus, lateral malleolus of the fibula and talus.
The joint capsule is attached upon the edges of the articular
surfaces. Anterior and posterior parts of the capsule are thin; from each
side it is supported by the strong collateral ligaments.
The deltoid (medial) ligament is very strong. It is attached from
above to the medial malleolus, from below – to the navicular, heel bones
and talus.
The lateral ligament consists of three bands:
o the anterior talofibular ligament passes from the lateral
malleolus to neck of the talus;
o the posterior talofibular ligament passes from the lateral
malleolus to the lateral tubercle of the talus;
o the calcaneofibular ligament passes from the lateral malleolus
to the lateral surface of the heel bone.
Weak places of the joint capsule are located in front under the
tendons of extensor muscles and from behind on each side of the
Achilles tendon.
Region of the foot
Borders: distal part of the lower extremity which is located lower
than the horizontal plane drawn through the right and left malleoli.
Dorsal and plantar surfaces are distinguished in region of the foot.
Dorsal surface of the foot
The skin is thin.
The subcutaneous fat is poor developed, contains the dorsal
venous arch (from which the great and small saphenous veins begin),
saphenous nerve (innervates skin of the medial part of the foot),
superficial peroneal nerve (innervates the dorsum skin of the foot from
the first to medial surface of the fourth toes except the first interdigital
space), deep peroneal nerve (innervates skin of the first interdigital
space) and sural nerve (innervates skin of the dorsum of foot of the
medial surface of the fourth toe and skin of the fifth toe).
The superficial fascia.
Between the layers of the deep fascia tendons of the anterior tibial
muscle, long extensor muscle of the great toe, long extensor muscle of
the toes and dorsal neurovascular fascicle (dorsal vessels of foot and
deep peroneal nerve) are located. The dorsal artery of the foot is
prolongation of the anterior tibial artery. Along its course the artery
gives lateral and medial tarsal arteries and three terminal branches: the
arcuate artery (from it three dorsal metatarsal arteries begin), deep
plantar branch (anastomoses with lateral plantar artery) and first dorsal
metatarsal artery.
The short extensor muscle of the great toe and short extensor
muscles of toes are located under the deep fascia.
The dorsal surface of the tarsal and metatarsal bones and
interosseous fascia which covers four dorsal interosseous muscles of the
foot.
Plantar surface of the foot
The skin is thick.
The subcutaneous fat is pierced by fibrous intersections which
connect skin with plantar aponeurosis. Medial calcanean branches of the
tibial nerve, branches from medial (supply three medial toes and medial
surface of fourth toe) and lateral (supply fifth toe and lateral surface of
fourth toe) plantar nerves pass in it.
The plantar aponeurosis is formed by induration of the deep fascia
in the center of plantar surface of the foot and located between the
calcaneal tuber and the base of the toes.
The subaponeurotic compartment is divided by two longitudinal
fascial septums into three parts: medial, lateral and median.
The median subaponeurotic compartment contains short flexor
muscle of the great toe, abductor muscle of the great toe and tendon of
the long flexor muscle of the great toe. The calcaneal canal is located
in the proximal part of this compartment between the abductor muscle
of the great toe and calcaneal bone. The medial plantar neurovascular
fascicle passes in it.
The lateral subaponeurotic compartment contains muscles of the
fifth toe: abductor, flexor and opponens muscles of the little toe.
The median subaponeurotic compartment is divided by the
fascial septum into the superficial and deep parts. Superficial
compartment contains short flexor muscle of the toes, plantar quadrate
muscle, tendons of the long flexor muscle of the toes, lumbrical
muscles and adductor muscle of the great toe. The deep compartment
contains plantar interosseous muscles.
The neurovascular fascicles of plantar surface of the foot are
presented by the medial and lateral plantar arteries, veins and nerves.
The plantar arteries form the plantar arch at the level of the fifth
metatarsal bone base. The metatarsal plantar arteries which are divided
into the digital branches start from the plantar arch.
Talocalcaneonavicular joint
The talocalcaneonavicular articulation is a ball and socket joint: the
rounded head of the talus being received into the concavity
formed by the posterior surface of the navicular,
the anterior articular surface of the calcaneus,
and the upper surface of the plantar calcaneonavicular ligament.
There are two ligaments in this joint: the articular
capsule and the dorsal talonavicular.
tarsometatarsal joint
The tarsometatarsal articulations (Lisfranc joint) are arthrodial joints in the foot. The tarsometatarsal articulations involves thefirst, second and third cuneiform bone, the cuboid bone and the metatarsal bones. The eponym Lisfranc joint is named after 18th-19th century surgeon and gynecologist, Jacques Lisfranc de St. Martin.
The tarsometatarsal articulations (Lisfranc joint) are arthrodial joints in the foot. The tarsometatarsal articulations involves thefirst, second and third cuneiform bone, the cuboid bone and the metatarsal bones. The eponym Lisfranc joint is named after 18th-19th century surgeon and gynecologist, Jacques Lisfranc de St. Martin.
Structure
Bones
The
bones entering into their formation are the first, second, and third cuneiforms, and the cuboid bone, which
articulate with the bases of the metatarsal bones.
The
first metatarsal bone articulates with the first cuneiform; the second is
deeply wedged in between the first and third cuneiforms articulating by its
base with the second cuneiform; the third articulates with the third cuneiform;
the fourth, with the cuboid and third cuneiform; and the fifth, with the
cuboid.
The
bones are connected by dorsal, plantar, and interosseous ligaments.
The Dorsal Ligaments
The
dorsal ligaments are strong, flat bands.
The
first metatarsal is joined to the first cuneiform by a broad, thin band; the
second has three, one from each cuneiform bone; the third has one from the
third cuneiform; the fourth has one from the third cuneiform and one from the
cuboid; and the fifth, one from the cuboid.
The Plantar Ligaments
The
plantar ligaments consist of longitudinal and oblique bands, disposed with less
regularity than the dorsal ligaments.
Those
for the first and second metatarsals are the strongest; the second and third
metatarsals are joined by oblique bands to the first cuneiform; the fourth and
fifth metatarsals are connected by a few fibers to the cuboid.
The Interosseous Ligaments
The
interosseous ligaments are three in number.
·
The first is the
strongest, and passes from the lateral surface of the first cuneiform to the
adjacent angle of the second metatarsal.
·
The second connects
the third cuneiform with the adjacent angle of the second metatarsal.
·
The third connects
the lateral angle of the third cuneiform with the adjacent side of the base of
the third metatarsal.
Synovial Membrane
The
synovial membrane between the first cuneiform and the first metatarsal forms a
distinct sac.
The
synovial membrane between the second and third cuneiforms behind, and the
second and third metatarsal bones in front, is part of the great tarsal
synovial membrane.
Two
prolongations are sent forward from it, one between the adjacent sides of the
second and third, and another between those of the third and fourth metatarsal
bones.
The
synovial membrane between the cuboid and the fourth and fifth metatarsal bones
forms a distinct sac.
From
it a prolongation is sent forward between the fourth and fifth metatarsal
bones.
Function
The movements permitted between the
tarsal and metatarsal bones are limited to slight gliding of the bones upon
each other.
Clinical
significance
A Lisfranc injury is
common among athletes.
5. Classification of pyoinflammatory processes of the hand (whitlow, phlegmons). Operative treatment of whitlows. Principles of surgical treatment of pyoinflammatory processes of limbs.
WHITLOW
Whitlow is a surgical disease characterised by the development of a
pyoinflammatory process in the tissues of fingers.
Depending on localization the depth (extent) of finger’s tissue involvement
and clinical course there are uncomplicated (superficial) and complicated (deep)
forms of whitlow. The uncomplicated forms include cutaneous, subcutaneous,
subungual and paraungual (paronychia) whitlow. The complicated forms include
bony, articular, bonyarticular, thecal (tendovaginitis) whitlow and pandactylitis
(involvement of all anatomical structures of finger).
Whitlow also can be classified according to the stage of the process: serous
(serous-infiltrative) and purulent
(purulo-necrotic). The main method of
treatment for different forms of
whitlow in the purulo-necrotic stage is
a surgical operation.
The minimal number of incisions
on the lateral surface of the finger
should accompany the operation in case
of this disease to prevent the damage of
neurovascular fascicles and
development of cicatrical contracture
on the working surface of the finger
during a long-term postoperative
period. In addition, the incisions should be done according to the projection of
main neurovascular fascicles (to prevent gangrene of finger or its segments) not
touching the interphalangeal folds (to prevent damage of the ligamentous apparatus
of joints).
Anesthesia: general anesthesia; block anesthesia (by
Oberst-Lukashevich or Braun-Usoltseva) in case of
uncomplicated forms of whitlow.
Cutaneous whitlow
Localisation: under epidermis or in the papillary layer
of skin.
Surgical operation. Exfoliated epidermis is opened
by sharp Cooper's scissors or ophthalmic scalpel and the
content of the purulent cavity is evacuated. Exfoliated epidermis is dissected along
the margins of fixation.
Comletingf the operation. Washing the wound by 3% solution of hydrogen
peroxide and application of an aseptic spirit-hypertonic salt solution dressing.
Paronychia
Localization: nail wall. Types: superficial
(subepidermal) and profound.
Surgical operation. In case of a superficial
form see a cutaneous whitlow.
In case of a profound form the incision is made in the
centre of infiltration on the longitudinal axis of finger. After
this pus is evacuated. Surgical revision and washing the
wound is done. Wedge resection of the corners of the wound is performed.
In case of total involvement of the nail wall two parallel incisions are done
from the lateral sides beginning from the base of the nail plate (П-shaped incision).
The edge of the nail wall is raised and curettage of the cavity is performed by
Volkmann's curette.
Completing the operation. After washing the wound by 3% solution of
hydrogen peroxide turunda with spirit-hypertonic salt solution is introduced under
the nail wall. Aseptic dressing is applied on the finger.
Subungual whitlow
Localization: under the nail plate (between the nail
bed and nail plate).
Surgical operation depends on the location of a
suppurative focus.
If a suppurative focus is localized under the edge of
the nail plate then only the distal part of the exfoliated nail is
resected by Cooper's scissors. After this pus is evacuated.
If a suppurative focus is localized under the proximal
edge of the nail plate, the nail wall must be raised a little and
exfoliated from the nail. The proximal part of the nail plate is
resected by Cooper's scissors. The
unexfoliated part of the nail is usually
not resected for better healing. Then
pus is evacuated.
In case of total or subtotal
(more than a half of the nail bed)
exfoliation of the nail plate must be
entirely removed. For this purpose
the distal edge of the nail plate is
taken along by the nail extracting
forceps (or Cocker’s forceps) and
dislocated from the nail bed. After
this pus is evacuated.
Completing the operation. Washing the wound by
3% solution of hydrogen peroxide, removal of necrosis
foci and fibrin. An aseptic dressing is put on the finger.
Subcutaneous whitlow
Localization: subcutaneous fat of finger.
Surgical operation.
If a suppurative focus is localized in the distal phalanx a fusiform or Г-
shaped incision (if the suppurative process is localized in the lateral edge of the
distal phalanx) at the site of maximal fluctuation is usually
performed.
If the suppurative focus is localized in the medial or
proximal phalanx one-sided midlateral incision should be
done. The midlateral line is a line connecting the tops of
interphalangeal folds in case of the maximal flexion of
finger.
Completing the operation. After curettage of the
cavity by Volkmann's curette the wound is washed by
3% solution of hydrogen peroxide and the gauze turunda
and aseptic dressing is put on the finger.
Thecal whitlow (tendovaginitis)
Localization: vaginal synovial membrane.
Surgical operation. See the palmar
aspect of fingers and synovial sheaths of hand.
Completing the operation. Setting drainage and washing the wound by 3%
solution of hydrogen peroxide and antiseptics (chlorhexidine).
Bony whitlow
Localization: bones of phalanges.
Kinds: marginal, subtotal, total. Acute (without fistula) and chronic (with
fistula).
Surgical operation.
In case of acute whitlow a surgical operation
is usually done in two stages.
1. The first stage: Lancing the suppurative focus at
the site of maximal fluctuation of soft tissues.
Surgical revision by the Volkmann's curette.
Economical necrectomy. Polishing the sharp ends
of the cavity by rasp. Setting drainage into the
joint cavity and washing it by 3% solution of hydrogen peroxide and
antiseptics.
2. The second stage (after diminishment of acute inflammatory signs): Radical
osteonecrectomy, putting drainage and washing the joint cavity by 3% solution
of hydrogen peroxide and antiseptics, secondary suturing the wound.
In case of chronic whitlow a surgical operation is usually done in one stage.
The surgical approach is through the fistulous opening or primary operative
wound. Surgical d-bridement of soft tissues up to the bone. Osteonecrectomy by
the Volkmann's curette. Polishing the sharp ends of the cavity by rasp. Washing
the wound by 3% solution of hydrogen peroxide and antiseptics. Putting drainage
through the additional counterpuncture. Suturing the wound.
Articular whitlow
Localilzation: interphalangeal and
metacarpophalangeal articulations (without the
damage of the articular parts of phalanges or
metacarpal bones).
Surgical approach: through initial wound, at
the site of maximal fluctuation of soft tissues on
median-dorsal surface of the joint region.
Surgical operation. Surgical revision of
articulating surfaces through the incision of the
capsule of the joint. Washing the joint cavity by
solutions of antiseptics. Performing an additional
counterpuncture. Setting drainage through the
joint cavity (must be out of articular surfaces) for
fractional washing.
Completing the operation. After washing
the wound and drainage apply aseptic dressing on
the finger.
Bonyarticular whitlow
Localization: interphalangeal and metacarpophalangeal articulations (with
the damage of articulating surfaces and articulating parts of phalanges or
metacarpal bones).
Types: acute and chronic.
Surgical approach: see articular whitlow.
Surgical operation.
In case of an acute whitlow a surgical operation is usually done in two
stages.
1. The first stage: Surgical revision of articular surfaces through the incision of the
capsule of the joint is performed. By sharp scissors and Volkmann's curette
economical necrectomy (evacuation of devitalized tissue of the capsule,
articular surfaces and bony sequestrums of the joint) is done. The joint cavity is
washed by solutions of antiseptics. Setting drainage in the joint cavity for
fractional washing.
2. The second stage (after diminishment of acute inflammatory signs):
Osteonecrectomy by Volkmann's curette. Polishing the sharp ends of the bones
by rasp to form articular surfaces. Washing the wound by 3% solution of
hydrogen peroxide and antiseptics. Setting drainage and suturing the wound.
In case of chronic whitlow a surgical operation is usually performed in one stage.
Pandactylitis – involvement of all
anatomical structures of finger.
The surgical maneuvers and completing
the operations are similar to those in case of
bony, bony-articular and thecal whitlow.
Requirements for opening of the suppurative foci: lancing of all the pockets and purulent leakages, removal of the necrotic tissue, creation of free outflow of pus (drainage).
Rules of incision making on the fingers:
- in case of cutaneous and paraungual panaritium incisions are done in sites of maximal fluctuation;
- in case of subungual panaritium surgical approach depends on localization of suppurative focus: if it is localized under the nail plate edge
– wedge resection of the exfoliated nail distal part is performed and after that pus is evacuated, if it is localized under the proximal edge of the nail plate
– the proximal part of the nail plate is resected (unexfoliated part of the nail is usually not resected for a better healing);
- in case of subcutaneous or deep forms of panaritium:
a incisions should be located on the anterolateral surface of the finger to prevent damage of the neurovascular fascicles and loss of sensitivity of the working surface;
b incisions are done from both sides of the phalanx (basic opening on one side and counteropening in another) for better evacuation of pus;
c incisions should be made only through the phalanges without damaging of cruciate and annular ligaments of the fibrous sheath;
- in case of tendovaginitis incisions are done in each phalanx, as well as in region of head of the metacarpal bone;
- in case of tendovaginitis of I and V fingers incisions are done not only from both sides of each phalanx but along the tendons of long flexor muscles of the fingers on the palm taking into account «prohibited area of the hand»
.
Rules of incision making in phlegmon of the palm:
- in case of inflamation of the ulnar bursa drainage of pus is done from two incisions on the forearm which are located above the wrist joint along the edges of tendons of the superficial flexor muscle of the fingers;
- in case of inflamation of Pirogov-Paron fat space drainage is done from two incisions between edges of the deep flexor muscle of the fingers and quadrate pronator muscle.
6. Classification of fractures. Kinds of osteosynthesis (extramedullary, intramedullary, compressive distractive osteosynthesis).
Osteosynthesis
The most common operation on bones is osteosynthesis – reduction of bone fragments in fractures. At present osteosynthesis can be divided into the following types:
1. Extramedullary (extraosseous) – fixation of the bone fragments by means of wire ligatures (osteal bandage), compression screws and metal plates.
2. Intramedullary (intraosseous) – fixation of the bone fragments by metal, polymeric or metallopolymeric constructions (pins, fracture nails) inserted into the medullary canal. These constructions are evacuated after bone healing. Depending on the technique of pin insertion we distinguish:
a. antegrade intramedullary osteosynthesis (pin is inserted into the proximal fragment in direction to the fracture line);
b. retrograde intramedullary osteosynthesis (pin is inserted into the proximal fragment from the fracture line and then it is pushed in the opposite direction after reposition of bone fragments). Some surgeons use bone grafts for fixing the bone fragments instead of metal constructions. There are three types of osteal
osteosynthesis: extramedullary, intramedullary and combined. Advantages of osteosynthesis by means of bone grafts are as follows: the absence of necessity in repeated operations for removal of fixation device and acceleration of bone regeneration in the field of fracture.
3. Compressive-distractive osteosynthesis – fixation of the bone fragments with a special external fixator [apparatus] (Ilizarov's). The principle of this method of osteosynthesis consists in separation and coaptation of the bone fragments by means of drill [extension] wire, which is inserted through the bones and fixed to the rings of apparatus. Compression of the bone fragments accelerates regeneration of the bone and promotes fast formation of callus. Distraction of the bone fragments allows extending the extremity if it is necessary. Besides, application of acompressive-distractive apparatus enables to use the extremity immediately after operation that provides prophylaxis for the development of muscle atrophy, contractures in joints, decubital [pressure] ulcers, i.e. those complications, which are noted in application of plaster.
7. Classification of osteotomy. Indications.
Osteotomy
Osteotomy (dissection of a healthy bone) is an orthopedic operation, which is employed for correction of deformations and lengthening limbs. Sometimes osteotomy is performed to keep a graft.
There are the following basic types of osteotomy.
1. By purpose:
- correcting – correction of congenital or acquired limb deformations;
- lengthening – directed to limb lengthening.
2. By technique:
- closed – is done through small incisions of soft tissues, sufficient for osteotome insertion;
- open – is done after wide baring of bone. Open osteotomy allows visual supervising a course of operation, however, it is more traumatic.
3. By place: diaphyseal, metaphyseal, epiphyseal and supracondylar.
4. By form: oblique, transverse, ladder, spherical, corner. At osteotomy it is necessary to take into account two indispensable conditions:
- the area of contact of the bone surfaces should be maximal, that is important for regeneration of the bone;
- good fixation of the bone fragments in required position should be supplied.
Nowdays fixation of bone fragments is done by compressivedistractive apparatus after osteotomy for lengthening limbs or correction of their deformation.
8. Kinds of bone resection. Indications. Concept about osteoplasty.
Bone resection
Bone resection (its partial excision) is performed in pathological processes (tumors, osteomyelitis and deformations). The following types of bone resection exist.
1. By extent:
- partial (marginal) – the length of the bone does not change;
- complete resection – only the part of the bone is preserved and its length becomes shorter;
- extended– the entire bone is resected.
2. By technique:
- transperiosteal (the fragment of the bone is resected together with periosteum);
- subperiosteal (in case of bone resection periosteum is saved).
Depending on the indications and aims of operation, bone resection can be final (with removal of the pathological focus) and temporary (with operative approach).
Osteoplasty
Osteoplasty or transplantation of bones is an effective surgical manipulation for liquidation of congenital or acquired defects of bones. It also gives good outcomes in treatment of false joints and delayed reduction of fractures. Bone graft plays a role of a biological stimulator and "building" material. There are 4 types of osteoplasty:
1. autoplasty (patients’ bones are used);
2. alloplasty (corpse bones are used with preliminary conservation);
3. xenoplasty (animal bones are used);
4. prosthetics (polymer material is used).
9. Concept about operations on joints: arthrotomy, arthrorisis, arthrodesis, arthroplasty, joint resection, joint plasty (classification, indications).
Arthrotomy is the opening of the joint cavity. It is performed to
drain joint cavity in pyoinflammatory diseases or for the purpose of
operative approach to perform operations on a joint.
Arthrolysis is operation directed to excision of fibrous adhesions
in the joint cavity. The indication to such an operation is contracture of
the joint. The operation is performed on the safe articular surfaces of the
affected bones. The stages of the operation are arthrotomy, section of
adhesions, putting the articulating ends of bones in correct position,
inserting adipose tissue between them to prevent formation of new
adhesions.
Arthroplasty is operation directed to mobilization of an immobile
joint. Stages: arthrotomy, separation of the articular surfaces on joint
space, modeling or creation of bony ends close to normal configuration
of joint, covering articular surfaces with lata fascia, immobilization of
extremity, joint rehabilitation.
Arthrodesis is operation directed to immobilization of a mobile
joint in case of pathological mobility or hypermobility. Kinds:
1. Intraarticular – operation is performed by opening a joint cavity
and consists of the resection of articular surfaces or drawing on
them roughness and connection them by screws and nails with
subsequent limb immobilization in the functionally favorable
position;
2. Extraarticular – immovability in joint is created without its
opening by paraarticular introduction of bone graft or extracapsular
fixation of articular surfaces by means of metal plates;
3. Combined.
Nowardays compressive arthrodesis is often used, when
compressive apparatus fixes articular surfaces.
Operation of arthrorisis is done on joints with paralysis of the
separate group of muscles. This operation is directed to restriction of the
amplitude of movement or mobility in the joint. The principle of the
operation consists of creation of movement "terminator" in the joint.
Bony or metal plates can be used as "terminators" for this purpose. More
often such operation is done on the ankle joint so-called "tip foot", which
results from the damage of a common peroneal nerve or its deep branch.
In these cases posterior arthrorisis is done – bony plate is placed between
the calcaneal tuber and tibia. Sometimes the tendons of paralyzed
muscles are used for restriction of mobility in the joint instead of bony
plates, such operation is called tenodesis. However, because of relapses
which arise after the operation of tenodesis lavsan bands are used more
frequently, then it is called lavsanodesis.
The operation of joint resection is performed on wounds, purulent
lesions, tuberculosis and malignant neoplasms of joints. Depending on
the extent of the removed articular surfaces resection can be partial (one
articular surface or its part is removed) or total (both articular ends of
bones are removed). Depending on the technique of resection it can be:
1. intraarticular (intracapsular) – with opening the joint cavity;
2. extraarticular (extracapsular) – metaepiphyses of both bones
together with the capsule are resected in a single block without
opening the joint cavity;
3. extraarticular economical – with preservation of the metaepiphysical zone of growth (in children).
After joint resection ankylosis develops. However, joint resection
can be the first stage of the operation of endoprosthesis – joint plasty.
Today metallopolymeric prosthesises of different joints have wide
distribution. Allo- and xenografts of joints are used rarely.
10. Indications and technique of joint puncture. Complications.
Joint puncture
Joint puncture is performed both for diagnostic and for treatment.
So the presence of joint contents and its character are determined, that
considerably facilitates diagnosis. Treatment includes removal of
exudate, bathing joint and introduction of antiseptic solutions or
antibiotics in it. On washing of the joint cavity the quantity of injected
liquid shouldn’t be more than the quantity of evacuated one. Puncture is
repeated if it is necessary.
Technique of a joint puncture is rather simple but requires
following the rules of aseptics. It is usually performed under local
anaesthesia with a puncture needle (length 6-10 cm, diameter not less
than 1 mm) and 10-20 ml syringe. The skin must be removed (pulled
away) from the site of puncture to make a wound canal not straight,
thanks to this joint content doesn’t go out from the cavity after needle
extraction. The needle shouldn't be inserted too far in order to prevent
the damage of the articular cartilage. The moment of penetration into the
joint is based on disappearance of resistance, which the surgeon feels
during insertion the needle through soft tissues. Sometimes trocar is used
for a joint puncture. With puncture of big joints immobilization of the
limb must be provided within a day.
Points for joint puncture are as follows.
For the shoulder joint:
1. externally – in the middle of the distance between the end of
acromion and greater tubercle of humeri;
2. anteriorly – between the lesser tubercle of humerus and coracoid
process;
3. posteriorly – lower than the posterior edge of the coracoid process in
fossa formed by the posterior edge of deltoid and the inferior edge of
supraspinous muscles.
For the elbow joint:
1. externally – between the lateral condyle of humeri, lateral edge of
olecranon and head of radius;
2. posteriorly – above olecranon.
For the wrist joint:
on dorsum of the hand – on crossing the axis of II metacarpal bone
and line, connecting the styloid processes of ulna and radii
(between the tendon of extensor muscle of index finger and the
tendon of extensor muscle of thumb).
For the hip joint:
1. anteriorly – in the middle of the distance between the top of the
greater trochanter and point between the internal and medial third
of the inguinal ligament;
2. externally – above the top of the greater trochanter,
perpendicularly to the axis of the thigh.
For the knee joint:
1-2 cm from the lateral (or medial) side of patella by upper or
lower pole.
For the ankle joint:
in front – between the top of the lateral malleolus and the tendon of
the long extensor muscle of toes.
11. Classification and requirements to sutures of tendons. Kinds of sutures. Concept about tendon grafting.
Sutures of tendons are divided into the following groups:
1. Primary (during initial surgical d-bridgement).
2. Early delayed (after primary healing of a wound).
3. Late delayed (after secondary healing of a wound).
The requirements to tendon sutures are as follows:
1. They should be strong.
2. They shouldn’t involve much tissue not to disturb blood supply and
shouldn’t involve little tissue not to separate fascicles of the
tendon.
3. Knot should be inside the tendon because its surface should be
smooth.
4. Fascial and synovial sheath should be sutured.
Suturing of tendons is performed by silk, kapron, nylon, and also
by tantalum wire in diameter 0.1mm.
For improvement of the muscle function with posttraumatic
shortening of tendons tenotomy section of tendons is performed for their
subsequent lengthening. Z-shaped section of tendons (by Bayer) or
portioned tenotomy (by Vulpius) for this purpose are used. For
replacement of large defects of tendons auto-, allo- and sometimes
xenoplasty is performed.
12. Amputations of limbs: indications, classification, stages of operation.
AMPUTATIONS
Amputation is removal of the distal part of the limb at the level of
the bone.
Exarticulation is removal of the distal part of the limb at the level
of the joint.
All over the world 47% of amputations are performed due to
complications of the vascular diseases of extremities and 43% due to
traumas. The indications for performance of this operation are divided
into two groups:
absolute (or primary) indications, when a peripheric part of the
limb is nonviable, but the processes proceeding in it are not of a
mortal danger;
relative (or secondary) indications, when a peripheric part of the
limb is viable, but the processes proceeding in it are of a mortal
danger.
Absolute indications
1. Necrosis of the distal part of the extremity, gangrene due to
vascular occlusion, the fourth-degree burn and frostbite.
2. Total extremity avulsion with impossibility of replantation.
For extremity replantation after total avulsion a number of
conditions including preservation of tissue viability,
especially magistral vessels, qualification of the surgeon,
opportunity of subsequent supervision are necessary.
3. Combination of three factors: crushing of a bone, muscles
more than 2/3 of the diameter, a total (complete) rupture of
magistral neurovascular fascicles.
4. Combination of two factors: crushing of joints and total
rupture of magistral neurovascular fascicles.
Relative indications
1. Gas gangrene.
2. Acute purulent inflammation with danger of sepsis.
3. Chronical long-term specific or nonspecific inflammation
with danger of internal organs amiloidosis.
4. Malignant tumors.
5. Defects and acquired deformations that cannot be corrected.
Classification of amputations
Depending on the terms of performance we distinguish primary,
secondary and repeated (reamputation) amputations:
primary amputation is a removal of the injured part of the
limb during the first 24 hours after injury while performing
initial surgical d-bridement, i.e. before the development of an
inflammatory process in the wound;
secondary (delayed) amputation is made when life
threatening complications are revealed (over about 7-8 days);
reamputation amputation is a repeated amputation of the same
limb performed at the wrong level of the previous
amputation, vicious amputation stump (impossible to use
prosthesis), phantom pains, causalgia and other
complications, which have arisen after amputation.
Depending on the form of soft tissue section we distinguish
circular, ellipsoidal and flapped amputations.
In circular (round) amputations the line of incision is cross to the
axis of the limb. Circular amputations depending on the technique of soft
tissue section can be divided into:
guillotine – all soft tissues and bone are dissected at the same
level at once. The advantages of this amputation are speed of
performance, maximal preservation of the limb length,
opportunity of anaerobic infection prophylaxis and fight
against it (bone exposures and vicious amputation stump are
formed because of soft tissue contraction and good
"irrigation" by oxygen).
Guillotine amputation is performed more frequently in an
anaerobic infection, when it is difficult to establish the extent
of the process distribution. Reamputation is always necessary
after the performance of guillotine amputation to liquidate a
vicious stump, which is not suitable for prosthesis.
single-staged – all soft tissues are dissected at one level, the
bone is dissected at the level of contracted muscles.
two-staged – at first skin, subcutaneous fat, own fascia are
dissected; then – the muscles at the level of the contracted
skin; after that – the bone at the level of the contracted
muscles.
three-staged – at first the skin, subcutaneous fat, own fascia
are dissected; then – the superficial muscles at the level of the
contracted skin; after that – the deep muscles at the level of
the contracted superficial muscles; then – the bone at the level
of the contracted deep muscles.
At ellipsoidal amputations the line of incision is oblique to the axis
of the limb.
In flapped amputations one (single-flap) or two (double-flap) flaps
from soft tissues are formed. In single-flap amputation the length of the
flap must be equal to the diameter of the limb, with double-flap – the
length of both flaps must be equal to the diameter of the limb. Besides,
due to the length of a flap it is necessary to make amendment on
contraction of the skin because of its elasticity (from 3 up to 8 cm
depending on the area). Alongside with the definition of the flap length
the choice of surfaces, where a postoperative scar will be is an important
point (it should not be on the working surface). They are anterior and
medial surfaces for the upper limb; inferior and posterior – for the lower
limb.
According to the cover of the bone flapped amputation can be
divided into:
fascioplastic – bonesaw-line is covered with skin, subcutaneous fat
and own fascia;
mioplastic – bonesaw-line is covered with skin, subcutaneous fat,
own fascia and muscles;
tendoplastic – bonesaw-line is covered with skin, subcutaneous fat,
own fascia and tendon;
osteoplastic – bonesaw-line is covered with skin, subcutaneous fat,
own fascia and bone.
Circular amputations have some advantages in comparison with the
flapped one:
section of the limb is performed at the lower level with the
formation of a longer stump;
lesser probability of soft tissue ischemia development.
However, circular amputations have a very important and essential
disadvantage – a scar is always on the working surface of the stump and
constantly can be injured by prosthesis.
Stages of amputation
Amputation includes four basic stages:
the first stage – definition of the level and type of amputation (site
of amputation);
the second stage – section of soft tissues;
the third stage – treatment of periosteum and bone section;
the fourth stage – treatment of vessels, nerves, muscles and stump
formation.
The level of amputation is the site of bone section, which
determines the length of the stump and its functionality. The efficiency
of modern prosthesis has eliminated the time-honored "sites of election".
Generally, the pathology determines the site of amputation with the
purpose of preserving as much length as possible. This is particularly
true of the upper extremity. The rule of saving all possible length is not
referred necessarily to the entire lower extremity. However, whenever
possible, the knee should be saved, since it provides major functional
advantages. Although the blood supply to the upper extremity is usually
adequate, the reverse is often true for the lower extremity.
Spinal anesthesia is commonly used for major amputation of the
lower extremities, inhalation anesthesia for major amputations of the
upper extremities, and plexus block or local infiltration anesthesia for
amputation of the fingers and toes.
In amputations of the upper extremity, the patient is placed near the
edge of the table with the arm extended and abducted to the required
position. For amputations of the lower extremity, the leg may be elevated
with several sterile towels under the calf.
In the absence of infection, the extremity is elevated to encourage
venous drainage before a tourniquet is applied. The tourniquet is placed
above the knee for amputations of the lower leg and foot, in the upper
thigh for amputations of the knee and lower thigh, and above the elbow
to control the brachial artery for major amputations of the forearm. In
cases of arteriosclerosis, the tourniquet should not be used because of the
possibility of damaging the blood supply to the stump. Also a tourniquet
can’t be used in the injury of thigh and shoulder, and in gas gangrene. In
this case the ligation of the vessel in a course is done. Sterile elastic
bands may be applied to the base of the digit for minor amputations.
The method of section of soft tissues is determined by the type of
amputation – circular or flapped. The incision is performed through the
skin and subcutaneous tissue downward the fascia, over the underlying
muscles.
The important stage of amputation is treatment of periosteum and
sawing the bone. There are three ways of periosteum treatment:
aperiostal – removal of periosteum 3-5 mm proximally to bonesawline;
subperiostal – section of periosteum is distal to bonesaw-line (it is
used in children);
transperiostal – the same level of periosteum and bone section (bad
– formation of osteofits (regeneration of periosteum)). Due to this
transperiostal approach is used only at guillotine amputation.
After periosteum treatment sawing the bone is done. Bone section
is performed simultaneously on the forearm and leg, avoiding probable
"infracture" by one of them at the end of sawing.
The fourth stage of amputation includes treatment of vessels,
nerves and muscles.
Ligation of vessels is done in two stages. At first the vessels of
large and middle calibre are ligated. On the large vessels (femoral,
axillary arteries) two ligatures are recommended to put (one with
suturing) for greater reliability. On the arteries of smaller calibre it is
enough to perform one ligature. It is forbidden to use common ligature
for arteries and veins situated near each other. Because of different
elasticity of vessel walls such ligature can slide off, that will result in a
secondary bleeding. Each vessel should be ligated separately. It is
desirable to ligate vessels, even large, with catgut – resorbable suture
material. Use of silk (nonabsorbable material) can result in infiltration of
tissues, formation of suture sinuses, rough scars which complicate
rehabilitation and prosthetics. Small vessels are ligated after making
tourniquet loose that results in insignificant bleeding and "marks" of
vessels. In these cases ligation of vessels with suturing is performed.
Careful hemostasis on the end of the stump is a preventive measure for
formation of hematoma which can lead to abscess, focal necrosis, rough
scars of a connective tissue.
At performance of stump toilet (treatment) each nerve should be
cut above the level of amputation by 4-5cm for prevention of neuroma
ingrowth in the postoperative scar. Section of a nerve is made by one
movement of the safe razor edge for a minimal trauma of the nerve. It is
necessary to inject 1% solution of Novocain under epineurium and
cautiously to move apart surrounding tissues up to the level of the
planned section before this manipulation. It is impossible to extend a
nerve by means of tweezers or clips to prevent rupture of its fibres,
intratrunkal hemorrhage and formation of adhesions with the
surrounding tissues. In addition, it is necessary to perform section of all
nerves including skin nerves by the described method for prevention of
phantom pains in the stump.
Amputation is ended by a wound closure. If a guillotine type of
amputation was performed, the wound is left open to be closed later in a
delayed manner, or the limb may be reamputated at a higher level to
permit primary closure. There are the following rules of wound closure:
antagonistic muscles are sutured;
deep and superficial fascia must be sutured for formation of a
mobile postoperative scar;
catgut is used for suturring (except for skin). Application of
resorbable suture material reduces the development of a connective
tissue around the ligatures and finally promotes formation of
amobile postoperative scar;
wound suturing is performed in a such way to prevent the
formation of a scar on the working surface;
postoperative wound must be drained
A planned program of rehabilitation is very important regardless of
the type and extent of the amputation, and a coordinated follow-up
involving a surgeon, physical therapist and prosthetist is necessary. The
patient requires complex medical care during a rehabilitation period
consisting of preparation of a high-grade stump. The requirements to a
high-grade stump are as follows:
stump should be painless;
joints located proximally to the level of amputation should
maintain normal mobility;
soft tissues of the stump should withstand (tolerate) well physical
activity.
All types of prostheses divide into: cosmetic, working, myotonic,
bioelectric. Prosthetics can be done immediately after operation
(express-prosthetics) or during a remote postoperative period.
Stumps not suitable for prosthetics are called vicious amputation
stumps. The basic causes for vicious stump formation:
1) location of rough, motionless, adhesioned with a bone scar on
the working surface;
2) sharp morbidity of the stump;
3) chronic inflammatory process in the stump;
4) osteophytes due to incorrect bone sawing.
Stump functionality depends on the correct choice of amputation
method, following the rules of technique and qualified realization of a
postoperative period. Vicious amputation stumps require repeated
correcting operation (reamputation). Sparing operations directed to
correction of stump defects are used nowadays. These operations are
performed on soft tissues, bones, nerves.
13. Formation of somatic nerve plexuses. Branches of cervical, brachial, lumbar and sacral plexuses. Anatomical structure of peripheral nerve.
Formation of somatic nerve plexuses
Cervical plexus C1 to C4
Brachial plexus C5 to T1
Lumbar plexus L1 to L4
Sacral plexus L5 to S4
Coccygeal plexus S4, S5, Co
For Branches of plexuses
Anatomical structure of peripheral nerve
14. Classification of injuries of nerve. Pathomorphology of nerve in case of it’s injuring.
Injury of nerves
Injuries of a nerve can be divided into closed and open according to
safety of epinevrium. In closed injuries the integrity of the external
membrane of a nerve is saved. Depending on the character of
morphological changes in the nerve there are the following kinds of
closed injuries:
a) Commotio – occurs as a result of influence of force away from the
nerve. Thus, there are no morphological changes in the nerve trunk,
but a short-term (within some hours or days) disorder of impulse
conduction is observed.
b) Сontusio – arises in more severe trauma with formation of
morphological changes inside the trunk (hemorrhage, sprain of
axons, rupture of fibres or fascicles). The duration and character of
the impulse conduction disorder depend on the extent of the nerve
fascicle damage and secondary scarry changes in the nerve trunk.
c) Сompressio – is caused by foreign bodies, bone fractured
fragments, paraneural haematomas, excessive and long-term
compression of the limb by tourniquet. The duration and character
of the disorder of impulse conduction depend on the duration of
influence of the agent causing compression.
d) Luxatio – results from the damage of fascial intersection fixing the
nerve to a bony groove. As a result of repeated dislocations
traumatic neuritis develops followed by local thickening the nerve
with the extensive growth and scarry changes of a connective tissue
(fibrous perineuritis).
e) Distorsio – is a severe form of closed damages. It develops usually
as a result of dislocations and fractures of bones accompanied by
sharp traction of the extremity and nerve trunks to the extent of
their elasticity and extensibility.
Open damages of the nerve trunk are accompanied by damage of
epinevrium. The wounds of nerves are divided into stab-incised and
gunshot. The rupture of a nerve can be complete or partial.
With the damage of nerves motor, sensitive, vasomotor, secretory
and trophic disturbances arise.
Motor disturbances include paresis, paralysis or atrophy of
muscles, decrease of tonus and disorder of tendon and periosteal
reflexes. In the remote period the development of movement restrictions
in the appropriate joints is possible.
Disturbances of sensitivity are shown in the form of its loss
(hyposthesia, anesthesia) and irritation (hypersthesia, pain).
Vasomotor-secretory disturbances are characterized by angiospasm
occasionally leading to expansion of the vessels strengthened by local
sweating (hyperhidrosis) and increased polymorphic reflex ("gooseflesh").
Trophic disturbances are the most severe. They manifest as
turbidity, banding and nail fragility, desquamation of epidemis,
hyperkeratosis, indolent trophic ulcers (of the first finger, heel, lateral
half of the foot).
After trauma which leads to damage of nerve fibres integrity, the
processes of degeneration and regeneration develop in the nerve. These
two phenomena are closely interconnected and are synchronized. The
damage of nerve results in the following pathomorphological changes:
1) Retrograde degeneration of axons is observed in the central end of
the nerve at the level of the wound and above the site of the trauma. The
intensity of retrograde degeneration depends on severity of the trauma.
In severe, usually gunshot wounds nerve fibres and tunics of the nerve
are exposed to necrosis to a significant extent (10-15 cm). In the damage
of the nerve by a sharp cutting thing the zone of necrosis is much less (5-
10 mm) than in the trauma produced by a blunt subject;
2) Wallerian [secondary] degeneration (Waller, 1852) of axons is
noted in the peripheric end of the nerve.
Nerve fibres separated by the trauma from the nerve cells in the
peripheric end of the nerve are exposed to degeneration. It consists of
disintegration of the axial cylinder on fine granules, and its myelinic
membrane – on fatty drops, which are resorbed completely beginning
from the site of the wound up to the terminal nervous endings on
periphery. The disintegration and degeneration of the peripheric neuron
begin immidiately after the trauma of the nerve (within the first 24 hs)
and finish by the end of the 1-st month when a complete pattern of nerve
degeneration develops.
Some days later after the trauma growth or regeneration of axons is
observed (the axial cylinders begin to thicken and produce “bulbs of
growth” in the connective tissue towards a peripheric end) in the central
end of the nerve. Having reached it in the absence of diastasis young
axial cylinders will penetrate in empty Schwann tunics, along which they
continue to grow untill achieve a peripheral receptor. If during this
regeneration axons do not find appropriate empty Schwann tunics of the
peripheric end of the nerve due to the large divergence of the ends of a
damaged nerve or insuperable obstacle (muscles, bone fragment, dense
scar) regeneration gets chaotic character with the formation of axon
glome (neuroma).
Depending on the type of regeneration there are:
1. true regeneration – axons sprout in its own Schwann tunics;
2. heterotopic regeneration – axons sprout in Schwann tunics of the
other but homogeneous axons (motor axons in motor tunics);
3. heterogeneous regeneration – axons sprout in Schwann tunics of
non-uniform axons (motor axons in sensitive tunics).
After true or heterotopic regeneration the function of the nerve will
be restored.
15. Suture of nerve (classification, requirements). Kinds of nerve regeneration.
Suture of nerves
According to the time of performance there are primary (during
initial surgical d-bridgement), early delayed (after primary healing of the
wound), late delayed (after secondary healing of the wound).
Primary suture can be done in the following conditions:
1) when the wound is cutting and clean;
2) when the surgeon has qualification and time;
3) when a neurological investigation of the patient is possible;
4) when the hospital has equipment for neurological operations.
Advantages of a delayed suture:
1) manipulation in a clean wound;
2) high qualification of the surgeon;
3) detailed neurological investigation of the patient;
4) easy determination of the border of nerve resection.
According to the technique (approach) of suturing we distinguish
epineural and perineural sutures
Requirements to nerve suture:
shouldn’t be torsion of a nerve around longitudinal axis;
diastasis between the ends of nerve – 1 mm.
Depending on the type of regeneration there are:
1. true regeneration – axons sprout in its own Schwann tunics;
2. heterotopic regeneration – axons sprout in Schwann tunics of the
other but homogeneous axons (motor axons in motor tunics);
3. heterogeneous regeneration – axons sprout in Schwann tunics of
non-uniform axons (motor axons in sensitive tunics).
After true or heterotopic regeneration the function of the nerve will
be restored.
16. Classification of bleedings. Ways of bleeding arrest.
Classification of bleedings is based on clinicoanatomic signs. An acute bleeding is characterized by fast development of clinical signs of hemorrhage. A chronic bleeding does not have so pronounced clinical picture, often recurs, is mild in volume and results gradually in development of anemia.
Depending on the site of bleeding one can distinguish:
a) tissue hemorrhage when blood leaving vessels impregnates the surrounding tissues causing formation of petechias and bruises;
b) external hemorrhage which is characterized by bleeding into the external environment;
c) internal hemorrhage which is characterized by bleeding into the
cavities of a human body. It can be open, if the cavity (stomach, uterus) communicates with an environment and closed, if the cavity is closed (abdominal cavity, pleural cavity, pericardial cavity).
Depending on the kind of the injured vessel bleeding can be
subdivided into:
a) arterial;
b) venous;
c) capillary;
d) mixed.
In addition, bleeding can be parenchymatous in case of the liver,
spleen and kidney injury.
Methods of bleeding control
In clinical practice there are temporary and constant bleeding
controls (hemostasis).
1. Temporary control of bleeding is performed by:
a) application of tourniquet;
b) pressure [compressive] bandage;
c) maximal flexion of the limb in the joint;
d) tight tamponade of the wound;
e) digital occlusion in the course of the vessel;
f) digital occlusion of the vessel in the wound;
g) clipping the vessel;
h) temporary prosthetics of the vessel.
Rules of tourniquet application:
it is allowed to hold it no more than 2 hours in summer and 1 hour
in winter (longer vascular embarrassment results in necrosis of the entire extremity). If more than 2 hours have passed from the moment of bleeding it is necessary to remove tourniquet for 10-15 minutes and apply it again a little above or below the previous site. Within this period arterial bleeding is arrested by manual pressing of the vessel in the wound through the bandage or in the course of the vessel.
it is necessary to attach a note with the indication of the date and exact time (hour and minute) of tourniquet application to control the duration of tourniquet application;
the site of tourniquet application should be wrapped by some material (towel, gauze, fabric of clothes) not to damage the skin and superficial nerves;
Pressure [compressive] bandage combined with immobilization and elevated position of the extremity is a good method for control of bleeding from the veins and arteries of a small calibre. The rule of pressure bandage application: some layers of sterile gauze are imposed on the wound, the top of which is covered by a layer of sterile cotton cloth, and both layers are fixed to the wound by circular bandaging. Maximal flexion of the limb in the joint results in compressing major vessels that interrupts inflow of blood to the injury of its wall.
Digital occlusion in the course of the vessel is applied in a shortterm
control of a bleeding. Typical sites of compressing a vessel to the
bone are as follows:
a) transverse process of C6 vertebra – common carotid artery;
b) the 1st rib – subclavian artery;
c) medial side of the humeral bone – brachial artery;
d) pubic bone – femoral artery.
Digital occlusion of the vessel in the wound for a temporary control of bleeding is used mainly during surgical procedures and sometimes during management of pre-medical care. The method of temporary prosthetics is used in the damage of the major vessels (femoral and brachial) in the diameter not less than 4-5 mm. Prosthetics is performed by a polymeric tube, which is inserted into the central and peripheric ends of the injured vessel after washing it by a solution of heparin and is fixed by ligature. The temporary prosthesis allows to recover the blood flow in the limb and to transport the patient to a specialized vascular surgical department.
2. Methods of constant control of bleeding:
a) mechanical (ligation of the vessel, suture of the vessel);
b) physical (electrocoagulation, laser coagulation);
c) chemical (Са, aminocapronic acid);
d) biological (blood preparations, hemostatic sponge, fibrin coat,
tamponade with omentum).
The mechanical methods are the most effective in the injury of major vessels. At the current stage of surgery development major vessel ligation can be applied as a compelled operation only in exclusive cases. The ligation of the major artery is always dangerous and can result in gangrene or development of ischemic syndrome, called "disease of the ligated vessel".
17. Indications and technique of ligation of vessels in wound and in course. Concept of collateral and reduced circulation.
Ligation of vessels
Depending on the site of ligation there are:
a) Ligation of the vessel in wound.
Stages of operation: separation of the vessel ends, applying of two
ligatures on proximal end of the artery (one with suturing the vessel wall
to avoid sliding of the ligature) and another ligature on the distal end.
b) Ligation of the vessel in the course (at a distance).
Indications:
when bleeding is from the region which is hard to reach
(gluteal, deep region of the face);
when the injury is large with the disturbance of anatomy and
it is impossible to identify the source of bleeding;
in repeated bleeding and danger of bleeding from an
infectious wound;
when separaion of pulsing hematoma or aneurysm from blood
circulation is required;
when high exarticulation is performed (of the hip or shoulder
joint);
when amputation is performed because of gas gangrene
(application of tourniquet is contrindicated).
Stages of operation: operative approach to the vessel; separation of
the vessel from surrounding tissues; putting of two ligatures on the
vessel nearby proximal corner of operative approach (one – with
suturing), one ligature – near the distal corner of incision; section of the
vessel wall between ligatures together with sympathetic nerves (for
opening collaterals or prophylaxis of spasm (ligatures result in irritation
and reflex spasms of arterioles)).
Collateral blood circulation
Collateral blood circulation is circulation of blood from the
proximal to the distal part of the limb shunting the major arteries (via
anatomic collaterals = anastomoses).
It has been established that ligation of the major arteries is not
always accompanied by development of gangrene, and thus, the incidence of gangrene varies much and depends on the level of vessel
ligation and anatomic conditions for formation of collateral circulation,
i.e. blood inflow in the peripheric part of the limb by anatomic collaterals
– lateral branches and their anastomoses.
Optimal conditions for formation of collateral circulation are in the
areas where a muscular layer is apparent. The level of ligation of the
major artery is defined by the place of origin of the largest collateral. For
example, the best level of ligation of the axillary artery is proximally up
to the subscapular artery; brachial artery – distally to the deep brachial
artery origin; the femoral artery – distally to the deep artery of the thigh
origin.
Anatomic collaterals or anastomoses are divided into:
a) intrasystem which connects the vessels belonging to the basin of
one artery (for example, anastomoses between the branches of the
deep artery of the thigh and the descending artery of the knee);
b) intersystem (cross-system) which connects the vessels belonging to
the basin of different arteries located in different regions (e.g.
anastomoses between the branches of the femoral artery and
internal iliac artery).
The intensity of collateral circulation depends on the following
factors:
anatomic (diameter, quantity, angle of the origin of collateral
branches and level of ligation);
functional (spasm or dilatation of the collateral branches).
Reduced blood circulation is performed with the purpose to
enhance blood supply of tissues and diminish blood outflow (after the
ligation of the artery the ligation of the adjacent vein is performed).
18. Levels of ligation of axillary, brachial, femoral arteries. Ways of collateral circulation.
ligation of axillary
The axillary artery may be safely ligated without endangering the arm, but only in a
location proximal to the origin of the subscapular artery (and distal to the
thyrocervical trunk of the subclavian artery). The anastomotic network
surrounding the scapula provides an alternate path for collateral circulation
to the arm from arteries including the dorsal scapular
artery andsuprascapular artery.
Ligation of Femoral Artery
Ligation of Brachial Arteries
Distally to the deep brachial artery origin. Collateral circulation by the branches of the deep brachial artery to the elbow anastomosis.
19. Classification of sutures of vessels. Requirements to sutures of vessels.
Suture of vessels
Numerous experimental and clinical investigations have allowed
developing the requirements to vessels sutures:
a) they should be hermetic;
b) there should be no stenosis of the vessel lumen in the zone of
suture;
c) the ends of the vessel should be connected by intima;
d) there should be no suture material in the lumen of the vessel.
Without the following above-listed requirements certain
preconditions for thrombus formation at the site of vascular anastomosis
develop.
Classification
According to the approach:
manual;
mechanical (which is performed by means of vessel suturing
apparatus).
According to vessel circumference:
lateral suture – it is imposed on the longitudinal wound of the
vessel wall or on the cross wound which doesn’t exceed 1/3 of the
circumference;
circular suture – it is placed on the complete rupture of the vessel
or on the cross wound more than 2/3 of the circumference.
Circular sutures depending on the approach of anastomosis
formation are subdivided into 3 groups:
Blanket (Carrel’s, Morozov’s) sutures are the most widely used
when anastomosis between the vessel segments is formed by
blanket suture. However, despite technical simplicity, blanket
sutures have a number of disadvantages such as: the suture covers a
vessel by a tenacious ring; suture material is left in vessel's lumen;
hermetity of the suture is not always provided.
Everting suture (Sapozhnikov’s one) provides more close contact
of the internal layers of the sutured segments of vessels.
Invaginating (Solovyov’s) suture consists of immersing peripheric
end into the central part of the vessel by formation of a cuff at the
site of connection. These sutures can be applied only in
anastomosing vessels of different diameter, otherwise, constriction
occurs at the site of suture.
In addition to suture medical glue, electrical current of highfrequency,
laser "welding" are applied for connection of vessels.
20. Operations at occlusions and aneurysms of vessels. Concept about plastic and by-pass operations on vessels.
Reconstructive operations on vessels
Reconstructive operations are performed with the purpose of reconstruction of magistral blood circulation when vascular patency is
disturbed. The basic causes of vessel occlusion are as follows:
thrombosis, embolism and arteriosclerosis of obliterans. All
reconstructive operations on vessels are divided into desobliterating and
plastic.
Desobliterating operations are directed to reconstruction of
Occluded vessel patency. The kind of operation depends on the cause of
vessel obstruction and extent of change in the wall. In case of acute
thrombosis or embolism, when the wall of the vessel is not changed,
thrombectomy or embolectomy is usually performed. Depending on the
technique of removal they are divided into:
a) direct (through incision of the vessel);
b) indirect thrombectomy or embolectomy (from another vessel by
Fogarty catheter).
In case of an atherosclerotic occlusion and thrombosis of large arteries trombendarterectomy is usually performed (removal of thrombus
together with the thick injured intima).
Plastic operations are directed to replacement of the occluded
segment of the vessel with auto-, allo-, xenotransplantate or vascular
prostheses.
Operations aimed at creation of pathways for blood circulation are
widely employed in current angiosurgery, so-called bypass operations
(performing a new pathway of blood circulation shunting the occluded
segment of the vessel by means of vascular prosthesis or own vein).
Bypass operations are less traumatic as the involved segment of the
vessel is not resected.
Operations on aneurysms
There are three kinds of aneurysms: true, dissecting (intramural)
and false (traumatic).
True aneurysms are formed in case of dilatation of the vessel wall
affected by a pathological process. False (traumatic) aneurysms are
formed from the fibrous tissue around a hematoma in case of the injury
of the vessel.
Aneurysms also can be classified into arterial, venous and arterio venous.
Traditionally three groups of operations can be performed on
aneurysms:
1. The purpose of the first group of operations is to interupt blood
circulation in the aneurysmatic sac that will lead to thrombus and
obliteration of the sac cavity. Ligation of the afferent vessel
(proximally to the sac) is performed (according to Anel and
Hunter).
2. The purpose of the second group of operations is to separate the
aneurysm from blood circulation by ligation of the afferent and
efferent vessels (according to Antillus) or removal it as a tumor
(according to Fillagrius).
3. The purpose of the third group of operations is to restore blood
circulation by suturing the arterial fistula from the aneurysmatic sac
so called endoaneurysmorrhaphy (according to Matas, Petrovsky).
Nowadays, the most common operation is separation of the
aneurysm from blood circulation or removal it and replacement by
vascular prosthesis.
Endovascular surgery
Ch. Dotter and M. Judkins in 1964 suggested method of
percutaneous transluminal angioplasty. In 1976 A. Gruntzig made
balloon dilatation catheter and performed first successful endovascular
dilation. Ballon angioplasty nowardays is usually applied for treatment
of angiostenosis. But this method is not very effective in case of dense
(calcified) stenosis – restenosis is often developed in long term period.
To improve the results of balloon angioplasty it was proposed to
introduce to affected area of the vessel special steel structures – stents, which create a rigid frame inside the vessel and maintain lumen patency
for blood flow for a long time.
All stents can be divided by construction into tubular and wire, by
implantation technique – expanded with the help of ballon and selfexpanding.
There are two methods of stents installation:
1) installation into the vessel after predilatation balloon angioplasty;
2) installation without expansion of the vessel.
Different approaches for stents instalation are used depending on
location of damage of the vessel, condition of magistral and collateral
circulation, type of stent. Femoral access is most common, it allows to
use of large catheter guides and most of the implanted stents.
21. Concept about microsurgical operations on vessels. Operation of extremity replantation.
Microvascular Anastomotic Techniques
A large number of different techniques have been investigated for making
microvascular anastomoses. Additionally, varying clinical situations demand that
microsurgeons are familiar with a variety of different methods for making microvascular
anastomoses. Techniques can be classified into two main categories:
a. type of anastomosis
b. method of fixation.
Type of Anastomosis
Microvascular anastomoses can be classified according to the technique used for
their construction:
a. end-to-end anastomosis
b. end-to-side anastomosis
c. end-to-side branch anastomosis
d. end-in-end anastomosis
e. cuffing techniques.
Method of Fixation
Many methods of anastomotic fixation have been investigated since surgeons
first started using microvascular techniques. The goal has been to find simpler and
faster techniques without decreasing patency rates. Some methods have been more
successful than others.
Described anastomotic fixation methods include:
a. sutured anastomoses
b. laser techniques
c. electrocoaptation
d. mechanical devices
e. adhesives anastomoses.
Suturing is the most versatile method for making microvascular anastomoses. It
can be used in any clinical situation, whether technically straightforward or in very
awkward situations.
Operation of extremity replantation.
A.Indications
The level and extent of injury are the most important determinants in the decision
to proceed with replantation. In replantation, observation of functional results
at different anatomical levels guides our indications. Good candidates for replantation
include patients with amputating injuries of the thumb, multiple digits, hand,
and wrist. When the amputation occurs through the forearm, at the elbow, or at the
arm, only sharp or moderately avulsed injuries are considered favorable candidates.
Patients having guillotine-type amputations are the best candidates for replantation
because of the limited zone of injury, but this mechanism of injury is also the least
common. Most amputations occur by crushing or avulsion, which increases the
zone of damaged tissues, makes the surgical repair more difficult, and lowers viability.
The extent of the zone of injury generally determines whether a part can be
replanted.
In general, thumb replantation should be attempted when it is technically possible.
The function of a replanted thumb with return of at least protective sensation
is superior to that of a prosthesis for tasks requiring fine dexterity. The functional
results improve with more distal thumb replantations.
Traumas involving amputation of multiple digits are good candidates for replantation. It is often the case that surgeons can replant only the least damaged
parts. Digits can be transferred from their natural position to a more functional
position or to a more suitable stump. When possible, it is more appropriate to replant the central, middle and ring digits than the index and little fingers, which
are border digits.
B. Surgical Management
There is general agreement about the sequence by which to repair damaged structures
in replantation, although the level and type of injury may necessitate deviation
from the accepted pattern. The operative sequence is:
1. debride;
2. identify and tag vessels and nerves;
3. shorten and stabilize bone;
4. repair flexor and extensor tendons;
5. anastomose arteries;
6. repair veins;
7. anastomose veins; and
8. cover skin.
22. Operative treatment of varix dilatation of veins of lower limb.
Operations in varix dilatation of veins
Two main venous systems of the lower limbs may be varicosed, i.e.
may be dilated and tortuous. Usually it is related to the great and small
saphenous veins.
The existing methods of treatment for the varix dilatation can be
divided into four groups:
1. conservative;
2. sclerotherapy (injection therapy);
3. surgical;
4. combined therapy.
Conservative treatment by elastic stocking, bandage and etc.
should be used in very early cases of varicosity, for diffuse varicosity,
which is not related to incompetent perforators or the number of
incompetent perforators may be too numerous to attend singularly and in
cases of pregnancy.
Sclerotherapy is treatment of choice when varicosity is mostly
confined below the knee and caused by incompetent perforators. This is
also ideal for postoperative recurrent varicosity. All methods of
sclerotherapy can be divided into biological coagulation, electro- and
laser coagulation, injection-sclerotic therapy. The latter employs
sclerosants like ethanolamine, thrombovar and scleroven and is used to
damage the intima of the vein to produce sclerosis later on.
Surgical methods of treatment are divided into stripping (removal)
and ligature operations, venous valve formation and plasty of veins.
Having dealt with the sources of retrograde flow it may be required
to remove a few superficial veins which have been dilated over the years
by the unrestrained effects of increased intraluminal pressure. The
following operations can be performed:
By Madelung – removal of vein through the long incision along its
course.
By Babckock – removal of varicose vein (usually great saphenous
vein on the hip) by means of special director through 2 small incisions
(nearby the hiatus saphenus and above the knee joint).
By Narate – ligation and removal of the varix veins of the leg
through single incisions.
Operations with ligation of a varicose vein are as follows:
By Troyanov-Trendelenburg – proximal ligation of the great
saphenous vein near the hiatus saphenus (to prevent blood flow from the femoral into the great saphenous vein).
By Shede, Klapp – transcutaneous ligation of veins.
By Kockett – suprafascial ligation of communicants (to prevent
blood flow from the deep veins into the superficial ones).
By Linthon – subfascial ligation of communicants.
Nowdays the operation according to Troyanov-Trendelenburg-
Babckock-Narate is the most common in varix dilatation of veins.
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