FRONT OF THIGH

§ Surface Landmarks:
1. Ileac Crest – thick, curved bony margin
Laterally, lower margin of waist
Hands supported on it during relaxed standing posture
2. Anterior Superior Iliac Spine (ASIS) – anterior end of iliac crest
3. Tubercle of iliac crest – low bony prominence
On the outer lip of iliac crest
About 5 cm behind ASIS
4. Fold of Groin – shallow curved groove from ASIS to pubic tubercle
Overlies inguinal ligament
Separates front of thigh from anterior abdominal wall
5. Pubic tubercle – small bony projecCon
Medial end of fold of groin
6. Pubic crest – short bony ridge
Between pubic tubercle and pubic symphysis
7. Greater trochanter of femur – located a hand breadth below tubercle of iliac crest
Wide prominence
Just in front of hollow on the side of hip
8. Midinguinal point – midway between ASIS and pubic symphysis
Femoral artery and head of femur lie beneath it
9. Midpoint of inguinal ligament – midway between ASIS and pubic tubercle
Femoral nerve lies beneath it

• Midpoint of inguinal ligament lies slightly lateral to midinguinal point

10. Patella (Knee cap) – largest sesamoid bone of body

Develops in tendon of quadriceps femoris
Easily seen and felt in front of knee
Can be moved freely in fully extended knee
11. Ligamentum patellae – strong fibrous band
From patella to Cbial tuberosity
12. Tibial tuberosity – blunt prominence
In front of upper end of Cbia
Upper end of shin
13. Medial & lateral condyles of femur & Mbia – large bony masses at the sides of knee
Most prominent points – sides of femoral condyles – medial & lateral epicondyles
Vastus medialis – fleshy prominence above the medial condyle of femur
 (extended knee)
14. Adductor tubercle – bony projecCon
Uppermost part of medial condyle of femur
Where tendon of adductor magnus is aUached
Flex knee partly, wide-shallow groove posterior to vastus medialis
Tendon of adductor magnus felt here
Tendon can be traced down to the adductor tubercle

SKIN
à Studded with hair – region around pubic symphysis
à Presence of few sCtches indicates embalming for body preservaCon

SUPERFICIAL FASCIA
à 2 layers : 1) Superficial faUy layer
2) Deep membranous layer
-conCnuous with corresponding layers of anterior abdominal wall

Membranous layer
à Loosely aUached to deep fascia of thigh
à Near inguinal ligament, firmly aUached along a horizontal line “Holden’s line”
à Holden’s line – begins a liUle lateral to pubic tubercle & extends laterally for about 8 cm

Contents of Superficial Fascia

1. Cutaneous nerves
2. Cutaneous arteries
3. Great saphenous vein & its tributaries
4. Superficial inguinal lymph nodes

Clinical Anatomy: when urethra is injured in perineum, urine may flow deep into the
membranous layer of superficial fascia.
à This urine can pass up into the anterior abdominal wall ® upper part of thigh
à Firm aUachment of membranous layer to deep fascia along Holden’s line prevents
urine from descending into the thigh beyond the line.

Cutaneous Nerves
1. Ilioinguinal nerve Above subsartorial line (line along sartorius)
2. Femoral branch of genitofemoral nerve
3. Lateral cutaneous nerve of thigh
4. Intermediate cutaneous nerve of thigh
5. Medial cutaneous nerve of thigh Below subsartorial line
6. Saphenous nerve
7. Cutaneous branch of obturator nerve
 Lumbar Plexus

1. Ilioinguinal nerve (L1) – emerges at the superficial inguinal ring

Supplies skin at root of penis/mons pubis
Anterior 1/3rd of scrotum/labium majus
Superomedial part of thigh
2. Femoral branch of genitofemoral nerve (L1,L2) –
pierces femoral sheath & overlying deep fascia 2 cm below midinguinal point
Supplies skin over femoral triangle
3. Lateral cutaneous nerve of thigh (L2,L3) –
emerges behind lateral end of inguinal ligament
Divides into anterior and posterior branches
Supplies skin on anterolateral side of thigh
Anterior part of gluteal region

Clinical : “Meralgia Paraesthe5ca”

à Lateral cutaneous nerve of thigh may get entangled in inguinal ligament
à Pain on lateral side of thigh

Sites of sensory loss

4. Intermediate cutaneous nerve of thigh (L2,L3) –

branch of anterior division of femoral nerve
Pierces deep fascia at juncCon of upper 1/3rd and middle 1/3rd of thigh
 Divides into 2 or more branches
Supplies a strip of skin on front of thigh
Extending from sartorius to the knee
5. Medial cutaneous nerve of thigh (L2,L3) –
Branch of anterior division of femoral nerve
Divides into anterior and posterior divisions
Supplies skin on medial side of lower 2/3rd of thigh
6. Saphenous nerve (L3,L4) – branch of posterior division of femoral nerve
Pierces deep fascia on medial side of knee
Runs down in front of great saphenous vein
Supplies skin on medial side of leg and foot up to ball of the big toe
Before piercing deep fascia, saphenous nerve gives off infrapatellar branch, which
runs downwards and laterally, supplies skin over ligamentum patellae

Clinical : Injury to femoral nerve

à Sensory loss – anterior aspect of thigh & front of leg, including medial border
of foot Cll the ball of big toe

Sites of sensory loss

7. Cutaneous branch of obturator nerve (L2,L3) – small branch

Arises from anterior division of obturator nerve
Supplies lower 1/3rd of medial aspect of thigh

PATELLAR PLEXUS
à In front of patella, ligamentum patellae & upper end of Cbia
à ContribuCons:
1. Lateral cutaneous nerve (anterior division)
2. Intermediate cutaneous nerve
3. Medial cutaneous nerve (anterior division)
4. Saphenous nerve (infrapatellar branch)

CUTANEOUS ARTERIES
Small arteries arising from femoral artery
Seen liUle below inguinal ligament
1. Superficial external pudendal artery
Pierces cribriform fascia
Runs medially in front of spermaCc cord
Supplies external genitalia
2. Superficial epigastric artery
 Pierces cribriform fascia
Runs towards umbilicus
Supplies lower part of anterior abdominal wall
3. Superficial circumflex iliac artery
Pierces fascia lata to the saphenous opening
Runs upwards below the inguinal ligament
Anastomoses at the ASIS with deep circumflex iliac, superior gluteal & lateral
circumflex femoral arteries

GREAT/LONG SAPHENOUS VEIN

Largest and longest superficial vein of lower limb (Saphes-easily seen)
Beginning and course
à Dorsum of foot, medial side of dorsal venous arch
à Runs upwards in front of medial malleolus
à Along medial side of leg
à Behind knee
TerminaMon
à in thigh, inclines forwards to reach saphenous opening
à pierces cribriform fascia
à opens into femoral vein
Tributaries
à before piercing cribriform fascia – 3 cutaneous veins corresponding the arteries &
also many unnamed tributaries
à receives blood from anterolateral vein of thigh
posteromedial vein of thigh
deep external pudendal vein

SUPERFICIAL INGUINAL LYMPH NODES

à variable in number and size
à T shaped arrangement
1. Lower verMcal group
Drains lymph from most of the lower limb
2. Upper lateral group (Horizontal)
Drains lymph from lateral parts of infraumbilical part of anterior wall & gluteal
region
3. Upper medial group (Horizontal)
Drains lymph from medial parts of infraumbilical part of anterior abdominal wall
& external genital organs including terminal ends of urethra, anal canal & vagina

SUCUTANEOUS BURSAE in relaCon with patella

Prepatellar Bursa – in front of lower part of patella & upper part of ligamentum patellae
Infrapatellar Bursa – in front of lower part of Cbial tuberosity & lower part of ligamentum
patellae

Deep Bursa
1. Suprapatellar bursa
2. Deep infrapatellar bursa
DEEP FASCIA/FASCIA LATA
à Tough fibrous sheath
à Envelops whole of thigh like a sleeve
A`achments
1. Superiorly boundary line between lower limb & pelvis
Anteriorly – inguinal ligament
Laterally – iliac crest
Posteriorly – through gluteal fascia to the sacrum, coccyx & sacrotuberous ligament
Medially – pubis, pubic arch & ischial tuberosity
2. Inferiorly on the front & sides of knee
AUached to subcutaneous bony prominences & capsule of the knee joint
Posteriorly – strong popliteal fascia, conCnuous below with fascia of the back of leg

Clinical Anatomy
à Fascia lata is aUached to the inguinal ligament
à Extension of thigh pull the abdominal wall & makes it tense
à To relax the abdomen fully for palpaCon, the paCent is asked to draw the legs up
à This overcomes pull of the fascia lata on the abdominal wall

“Ilio5bial tendon gra;ing”

à IlioCbial tract is used to replace the dura mater or a ruptured tendon of a muscle

ModificaMons of Fascia Lata -IlioCbial Tract -Saphenous opening

1. IlioMbial Tract
Fascia lata is thickened laterally, 5 cm wide band
• A`achments
Superiorly 2 layers
Superficial (lamina) – aUached to tubercle of iliac crest
Deep lamina – capsule of hip joint
Inferiorly tract is aUached to a smooth area
anterior surface of lateral condyle of Cbia
• FuncMonal Significance
1. Site for muscle inserMon - 2 muscles inserted into its upper part
Between superficial & deep laminae
3/4th part of gluteus maximus & tensor fasciae latae
2. StabilizaMon of knee - in both extension & in parCal flexion
\used in walking & running
In leaning forwards with slightly flexed kness, IT tract- main support of knee against
gravity

2. Saphenous Opening
à Oval opening in the fascia lata
à Gap between superficial & deep strata of fascia lata
à Centre of opening – 4 cm below & 4 cm lateral to pubic tubercle
à About 2.5 cm long
à 2 cm broad
 à Lateral opening - sharp crescenCc lateral margin or falciform margin
In front of femoral sheath
à Medial ill-defined margin – deeper level
à Formed by fascia overlying pecCneus
à The fascia passes behind the femoral sheath
à Saphenous opening is closed by cribriform fascia, modificaCon of superficial fascia
à Structures passing:
1. Great saphenous vein
2. Superficial epigastric & superficial external pudendal vessels
3. LymphaCcs from superficial to deep inguinal nodes

Intermuscular Septa
Divide the thigh into 3 compartments
1. Lateral intermuscular septa
Thickest
Extends from ilioCbial tract to lateral lip of linea aspera (femur)
Separates anterior (extensor/front) & posterior (flexor/back) compartments
2. Medial intermuscular septum
AUached to lateral lip of linea aspera
Separates anterior compartment from medial compartment (adductor)
3. Posterior intermuscular septum
Poorly defined
Separates medial and posterior compartments

FEMORAL TRIANGLE (Scarpa’s triangle) *do all diagrams from BDC

Triangular depression
Upper 1/3rd of thigh
Immediately below inguinal ligament

Boundaries
Lateral – sartorius (medial border)
Medial – adductor longus (medial border)

Base – inguinal ligament

Apex – directed downwards
Point where medial & lateral boundaries cross
ConCnuous, below with the adductor canal
Roof
1. Skin
2. Superficial fascia, containing superficial inguinal lymph nodes, femoral branch of
genitofemoral nerve, branches of ilioinguinal nerve, superior branches of femoral
artery with accompanying veins & upper part of great saphenous vein
3. Deep fascia, including cribriform fascia covering the saphenous opening

Floor
GuUer-shaped, formed by 4 muscles, lateral to medial:
1. Iliacus
2. Psoas major tendon
3. PecCnius
4. Adductor longus

Contents
1. Femoral artery & branches
2. Femoral vein & tributaries NAV : Lateral to medial
3. Femoral nerve
4. Lateral cutaneous nerve of thigh
5. Femoral branch of genitofemoral nerve
6. Femoral sheath
7. Deep inguinal lymph nodes
8. FibrofaUy Cssue

1. Femoral artery
Traverses the triangle from base to apex
Gives off 6 branches – 3 superficial, 3 deep
2. Femoral vein
Medial to artery, posteromedial to artery at apex
It receives the great saphenous vein, circumflex veins & veins corresponding to
branches of femoral artery
3. Femoral nerve
Outside the femoral sheath
In the groove between the iliacus and psoas major muscles
-nerve to pecCnius arises from the femoral nerve just above inguinal ligament
Passes behind femoral sheath to reach anterior surface of pecCnius
4. Lateral cutaneous nerve of thigh
Crosses lateral angle of triangle
Runs on lateral side of thigh
Ends by dividing into anterior and posterior branches
Supply anterolateral aspect of thigh and lateral aspect of gluteal region respecCvely
5. Femoral branch of genitofemoral nerve
Occupies lateral compartment of femoral sheath along with femoral artery
Supply most of the skin over femoral triangle
6. Femoral sheath
Encloses upper 4 cm of femoral vessels
7. Deep inguinal lymph nodes
 Deep to the deep fascia
Medial to the upper part of femoral vein
Receive lymph from superficial inguinal lymph nodes, glans penis/clitoris & deep
lymphaCcs of lower limb

FEMORAL SHEATH
Funnel shaped sleeve of fascia
Enclosing upper 3-4 cm of femoral vessels
Asymmetrical
Lateral wall – verCcal
Medial wall – oblique, directly downwards and laterally

FormaMon
à Formed by downward extension of 2 layers of fascia of the abdomen
à Anterior wall – formed by fascia transversalis, lies in the anterior abdominal wall
deep to the transversus abdominis
à Posterior wall – fascia iliaca, covers iliacus muscle
à Inferiorly – sheath merges with connecCve Cssue around the femoral vessels

Compartments – 3
1. Lateral compartment – femoral artery & femoral branch of genitofemoral artery
2. Intermediate compartment – femoral vein
3. Medial compartment – smallest, “femoral canal”

FEMORAL CANAL
à Medial compartment of femoral sheath
à Conical in shape, wide above & narrow below
à About 1.5 cm long
boundaries
à 1.5 cm wide at base
à Base/upper end – “femoral ring” Anteriorly – inguinal ligament
à Femoral ring is closed by Posteriorly – pecCneus & covering fascia
condensaCon of extraperitoneal Medially – lacunar ligament (concave margin)
connecCve Cssue called Laterally – septum separaCng it from femoral vein
“femoral septum”
à Parietal peritoneum covering Inferior epigastric vessels – juncCon of anterior &
septum from above - depression lateral walls of ring
“femoral fossa”
à Femoral canal – lymph node of Cloquet/Rosenmuller, lymphaCcs & small amount of
areolar Cssue. It drains the glans penis/clitoris

Clinical Anatomy
FEMORAL HERNIA
à Femoral canal – area of potenCal weakness in the abdominal wall
through which abdominal content may bulge out à femoral hernia
à More common in females (inguinal hernia more common in males)
à b/c in females, femoral canal is wider, b/c of wider pelvis & smaller size of femoral
vessels in females
 Parts & contents: hernia comprises:
1. neck
2. sac
à coverings – various layers on the sac
à content – loop of bowel mostly

Course:
1. passes downwards through femoral canal
2. forwards through saphenous opening
3. finally upwards along superficial epigastric & circumflex iliac vessels

Treatment:
1. ReducCon : reverse course followed
2. Herniorrhaphy
3. Hernioplasty

StrangulaMon of femoral hernia cases

à Surgeon has to enlarge femoral ring
à Possible only by cukng lacunar ligament (medial boundary)
à Occasionally obturator artery may lie along edge of lacunar ligament, may cause
alarming haemorrhage

ABNORMAL OBTURATOR ARTERY

à normal, branch of internal iliac
à occasionally, anastomosis – large, appears to be branch of inferior epigastric
à abnormal artery passes lateral to femoral canal in contact with femoral vein &