Topography of the human foot. Topography of the lower extremities. Posterior thigh
Region boundaries. The area of the foot includes the distal part of the lower limb, located below the line connecting the ends of the ankles.
Layers. The surface layers of the area are skin, subcutaneous adipose tissue and superficial fascia.
Fascia of the foot. The superficial fascia in Fig. J& Projecti-foot is present only on the dorsal surface;
the osseous fascia is absent, it is replaced by the femoral artery with spurs that run in the vertical direction of the foot, connecting the proper fascia of the foot with the skin. Thanks to the spurs, the fiber of the plantar surface is cellular in nature and is dense. These fibrous spurs prevent the spread of infection.
Own fascia envelops the foot from all sides and is attached by spurs to the lateral surfaces of the 1st and 5th metatarsal bones and the lateral surfaces of the phalanges of the fingers. Thus, the dorsal and plantar surfaces of the foot are separated. In the middle part of the sole, its own fascia, due to the presence of longitudinal strands, is thickened in the form of a triangular plate. This section of its own fascia is called the plantar aponeurosis. From the plantar aponeurosis in depth to the metatarsal bones there are two partitions: to the 1st metatarsal bone, the internal
n to the 5th metatarsal bone - external. Thus, three fascial beds are formed on the plantar surface of the foot: external, median and internal.
In the distal region, the plantar aponeurosis at the level of the interdigital adhesions (commissures) has three commissural openings for the vessels and nerves of the fingers. The neurovascular bundles located here are surrounded by loose fiber (comiseural fiber), which is directly connected with the subcutaneous tissue of the plantar surface, and in depth - with the subgaleal fiber.
Arising here inflammatory processes can break into the subaponeurotic cellular space and lead to the development of subaponeurotic phlegmon of the foot, which spreads through the plantar and heel canals, through the ankle canal, into the deep space of the posterior bed of the leg.
In the depths of the foot, a deep sheet of its own fascia, plantar interosseous fascia and dorsal interosseous fascia are isolated. As a result, eight fascial beds are formed on the foot: three plantar (median, lateral, medial), dorsal facial bed of the pillar and four beds of interosseous muscles.
In the fascial beds of the foot are the muscles and tendons of the muscles of the lower leg. In the medial fascial bed are: short flexor of the 1st finger, abductor of the 1st finger and tendon of the long flexor of the 1st finger. The median fascial bed of the sole contains: the short flexor of the fingers, the square muscle of the sole, the tendons of the long flexor of the fingers with worm-like muscles and the adductor muscle of the 1st finger. The lateral fascial bed of the sole contains three muscles of the 5th finger: abductor, flexor and opposing, the latter is often absent. The extensor tendons of the 1st toe and toes are located in the dorsal fascial bed of the foot. In the interosseous beds are two interosseous muscles: dorsal and plantar.
Vessels and nerves of the foot. The anterior tibial artery and the deep branch of the peroneal nerve come to the rear of the foot from the anterior bed of the lower leg. The artery goes outward from the extensor tendon of the 1st finger and goes under the tendons of the short extensor of the fingers, not reaching the 1st interdigital space, it gives a. arcuata, in the future it will give off the digital arteries.
The continuation of the dorsal artery of the foot will be the deep plantar artery, which goes to the sole through the first intermetatarsal space.
Plantar neurovascular bundles are a continuation of the posterior tibial artery and tibial nerve (Fig. 57), which, after leaving the medial ankle canal, are divided into medial and lateral plantar neurovascular bundles. In the proximal part of the foot, after exiting the ankle canal, the neurovascular bundles are located in the calcaneal and plantar canals. The calcaneal canal is the gap between the calcaneus and the abductor muscle of the 1st finger. The plantar canal is a continuation of the calcaneal canal, it is bounded from above by the longitudinal ligament of the sole, from below by a deep sheet of fascia, and on the sides by fascial septa separating the inner and outer fascial beds of the sole. The channel passes into the median fascial bed of the sole (Fig. 58).
Of the two plantar arteries, the medial one is less developed. It goes with the nerve of the same name and veins in the medial bed of the sole, along the medial septum in the medial groove. The lateral plantar artery has a larger diameter and is the terminal branch of the posterior tibial artery. The lateral plantar artery, together with the veins and the nerve, goes first in the median bed, located under the short flexor of the fingers on the square muscle of the sole. Further, the neurovascular bundle goes in the lateral groove along the lateral septum, at the level of the base of the 5th metatarsal bone it again goes to the median bed, forms an arc here - arcus pJantaris, located under the oblique head of the adductor muscle of the 1st finger and in the region of the 1st the interosseous space connects with the deep branch of the dorsal artery of the foot (Table 8). Thus, all three fascial beds of the sole and the dorsal fascial bed of the foot are interconnected, which plays a certain role in the spread of phlegmon.
Table 8 Course of vessels and nerves on the foot
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The pulse points of the lower limb should be remembered, since the pulsation of the arteries is determined during the examination of patients with vascular pathology.
Pulse points of the lower limb. Pulsation a. dorsalis pedis can be identified in the region of the first interdigital space and in the middle of the distance between the ankles. Pulse on a. tibialis posterior is defined midway between the medial malleolus and the calcaneus. Pulsation of the popliteal artery is palpable in the middle of the popliteal fossa. Under the inguinal ligament, on the border of its outer and inner thirds, determine the pulsation of the femoral artery.
Veins of the lower extremities
The veins of the lower extremities are two relatively isolated systems - superficial and deep, the connection between which is carried out by communicating (perforating) veins.
Deep veins of the leg. On the foot and lower leg, deep veins (two each) accompany the arteries of the same name. From the largest veins of the lower leg, the anterior and posterior tibial, the trunk of the popliteal vein is formed.
The femoral vein, a continuation of the popliteal, accompanies the femoral artery. Along the way, the femoral vein receives the deep vein of the thigh and the paired medial and lateral surrounding veins.
At the level of the lower edge of the inguinal ligament, the femoral vein passes into the external iliac, which, together with the internal iliac in the retroperitoneal space, gives rise to the common iliac vein. The right and left common iliac veins form the inferior vena cava. Deep veins of the lower limb, located in a common connective tissue bed with arteries, are topographically constant. Throughout, they receive a very large number of small venous branches from the tissues surrounding them.
Superficial leg veins. The largest venous collectors located under the skin on the lower extremities include the great and small saphenous veins. The great saphenous vein (vena saphena magna) is the longest of the human saphenous veins. The vein started from the medial marginal vein of the foot, then goes in front of the medial malleolus, where the veins of the dorsal venous network of the foot flow into it. On the lower leg, the great saphenous vein is most commonly found in the groove that forms between the medial edge of the tibia and the muscles. Rounding the posterior inner surface of the femoral condyle, the vein runs along the inner edge of the lower half of the sartorius muscle, located above the long adductor and comb muscles. Having reached the lower horn of the sickle-shaped edge of the wide fascia of the thigh, the vein pierces the cribriform plate and flows into the femoral vein (saphenofemoral anastomosis). According to V. N. Shevkunenko and A. N. Maksimenkov, the level of the saphenofemoral fistula is at a distance of 2 to 5 cm from the inguinal fold.
Throughout the great saphenous vein, many collaterals flow, collecting blood not only from the lower limb, but also from the external genital organs, the anterior abdominal wall, skin and subcutaneous tissue of the gluteal region. The number, diameter and direction of collaterals are variable, which together determine the network-like or main structure of the subcutaneous venous network, usually associated with body type: brachiomorphic or dolichomorphic, respectively. Sometimes a large saphenous vein can be represented by two or three trunks. Additional trunks can accompany the main collector all the way, on the thigh or on the lower leg.
At the confluence of the great saphenous vein into the femoral vein, the external pudendal veins, superficial epigastric, superficial circumflex vein of the ilium flow into the saphenous vein. The veins that collect blood from the anteroexternal and copper of the alposterior surface of the thigh are quite large, flowing into the great saphenous vein on their own.
The depth of the great saphenous vein varies throughout the lower limb. On the lower leg, the vein is located inside the superficial fascia; in the area of the knee joint, the vein lies directly under the skin. With the transition to the thigh, the main trunk of the great saphenous vein is located on the wide fascia of the thigh.
The small saphenous vein (vena saphena parva) is a continuation of the lateral marginal vein of the foot. At the level of the lateral malleolus, many venous branches flow into it from the outer plantar surface of the foot. The vein is located on the lateral side of the Achilles tendon behind the lateral malleolus, then passes to the posterior surface of the Achilles tendon and lies in the groove between the two heads of the gastrocnemius muscle.
At the level of the upper third of the lower leg, the vein lies between two sheets of the lower leg's own fascia (Pirogov's canal). Having reached the popliteal fossa, the vein goes deep and flows into the popliteal vein. The small saphenous vein is more topographically constant. Doubling of the small saphenous vein is rare, as is the atypicality of its confluence with the popliteal vein.
There are many anastomoses between the small and large saphenous veins on the lower leg, the largest of them are located in the area of the knee joint.
Commu spicy veins. The system of superficial veins of the lower limb is connected throughout with the deep veins through the communicating veins.
Originating from the veins located in the subcutaneous tissue on the lower leg or thigh, the communicating veins pierce their own fascia and go to the deep veins.
Allocate direct communicating veins that directly connect the saphenous veins with deep ones. They are characterized by a direct direction, large diameter and are located mainly in the lower third of the lower leg.
Numerous indirect communicating veins connect the saphenous veins with muscular venous branches, which flow into the deep main vessels.
The number of communicating veins depends on the structure of the subcutaneous venous network: there are more of them with reticular branching, less with a pronounced main structure.
The largest number of communicating veins is located on the foot and in the lower third of the lower leg. Communicating veins have great importance in pathogenesis varicose veins veins of the lower extremities.
The veins of the lower extremities have a valve apparatus. The venous valve consists of two semi-oval leaflets that prevent the backflow of blood.
The largest number valves are located in the deep and communicating veins, which is directly dependent on their hemodynamic function.
The distance between the valves depends on their number. In the small saphenous vein, the valves are 25–35 mm apart from each other, in the great saphenous vein, the distance between them ranges from 35 to 90 mm, and in the deep veins, from 20 to 30 mm.
The saphenous veins of the leg can be used for venipuncture, and the great saphenous vein can be venesectioned. Puncture access through the femoral vein is widely used in cardiac surgery for probing the heart and performing transcatheter operations on the heart.
Projection lines of vessels and nerves of the foot area:
1. The dorsal artery of the foot (a. dorsalis pedis) is projected from the middle of the distance between the ankles to the first interdigital space.
2. The internal plantar artery (a. plantans medialis) is projected from the middle of the distance between the inner ankle and the Achilles tendon to the first interdigital space, or is projected along a line drawn from the middle of the inner half of the width of the sole to the first interdigital space.
3. The external plantar artery (a. plantans lateralis) is projected from the middle of the distance between the inner ankle and the Achilles tendon to the fourth interdigital space. or along a line from the middle of the width of the sole (or from the middle of the line connecting the tops of the medial and lateral malleoli) to the 4th interdigital space.
Knee-joint
The knee joint is the largest joint in the human body. Functionally and in form, it belongs to rotational-block-shaped.
The knee joint is formed by the articular surfaces of the thigh, the condyles of the femur, the patella and the condyles of the tibia. The congruence of the articular surfaces of the tibia is enhanced by interarticular cartilage - menisci, which are located on the condyles of the tibia. With their anterior and posterior ends, the menisci are attached to the intercondylar eminence. Anteriorly, the menisci are connected by a transverse ligament. The outer edge of the menisci is fused with the articular capsule. With sharp flexion in the joint with simultaneous rotation of the lower leg, ruptures of the meniscus can occur, more often the internal one, since it has a free anterior and posterior horn. In this case, the menisci are between the two condyles, as in millstones.
The knee joint is located in a thick fibrous capsule, which is reinforced by numerous ligaments. The lateral ligaments, the proper patellar ligament, the patella retainer, the transverse ligament, and on the posterior surface of the joint, the oblique and arcuate ligaments are distinguished.
Lateral ligaments prevent lateral movements, therefore, if these ligaments are damaged, rocking movements occur, the joint space becomes uneven on radiographs. A distinctive feature of the joint is the presence of intra-articular cruciate ligaments, anterior and posterior, lig. cruci a turn anterius et posterius. The main role of the cruciate ligaments is to limit the forward and backward displacement of the lower leg. Damage to the cruciate ligaments leads to gross instability of the joint. When damaged, movements of the lower leg back and forth relative to the thigh appear, the so-called drawer symptom.
The synovial membrane in front of the joint protrudes into the cavity in the form of two pterygoid folds, which contain a layer of fat, these are plica alarae, or fat bodies. Cruciate ligaments, menisci, fat bodies form a kind of depreciation system of the knee joint, a buffer-brake system, which is of great importance in the functioning of the joint.
The volume of the joint cavity is increased due to torsion of the synovial membrane. There are nine in total. The largest inversion is anterior superior, unpaired. It is formed due to the transition of the synovial membrane from the femur to the patella's own ligament. The remaining inversions, paired, are located around the cartilaginous cover of the condyles of the femur and tibia. They serve as a place of accumulation of exudate and blood. The puncture of the joint is made from the lateral points, indented posteriorly from the patella at the upper pole.
There are mucous bags in the joint area. In the bags in front of the patella (prepatellar), prepatellar bursitis may occur.
Practical lesson
Puncture of the joints of the lower limb.
Vascular operations. Ligation of blood vessels.
Venesection. Vascular suture
Puncture hip joint
Indications. Traumatic hemarthrosis, exudative arthritis.
Anesthesia. 1% solution of novocaine, lidocaine.
Access. The puncture of the hip joint is performed from the front or side (Fig. 59, 60). In anterior approach, the needle injection point is determined by drawing a straight line from the greater trochanter of the femur to the middle of the inguinal ligament.
Rice. 59. Puncture points of the hip joint: 1 - external and 2 - anterior points |
Technics. A long needle is injected into the point corresponding to the middle of the indicated line and advanced perpendicular to the skin surface to a depth of 4-5 cm. When the needle reaches the femoral neck, its end is turned inwards and, upon further advancement, penetrates into the joint cavity.
With lateral access, the tip of the greater trochanter of the femur is felt and a long needle is inserted over it perpendicular to the skin surface to a depth of 8-10 cm (see Fig. 60). If the needle rests against the neck of the femur, its end is slightly turned cranially (upward) and, moving the needle deeper, enter the joint cavity.
Puncture of the knee joint
Access. The patient lies on his back. The joint is punctured from the lateral or medial sides above the patella, on the side of the tendon of the quadriceps femoris muscle (Fig. 61). When puncturing from the lateral or medial side, the lateral edge of the patella is felt with the left hand and at the level of the middle of its length, immediately behind the edge, the needle injection site is determined.
Technics. Having shifted the skin downwards with the finger of the left hand, perpendicularly (parallel to the plane of the operating table), a puncture needle is injected and, with a careful movement, it is advanced through the skin, lateral ligaments and the articular capsule. When the needle passes through the capsule,
pa. The moment of puncture of the wall of the upper inversion is felt by overcoming the elastic resistance.
Having drawn a colored liquid (water with methylene blue) into the syringe, it is injected into the joint cavity, the needle is removed. Fluid should not leak from the puncture site. With repeated intervention, fluid can be removed from the joint cavity.
Operations on vessels
Tools. Scalpel, tweezers, surgical and anatomical, grooved probe, Cooper scissors, dissector, Billroth, Kocher, Halsted hemostatic forceps, vascular scissors, sharp and blunt hooks, needle holder, surgical needles, atraumatic needles, Deschamps ligature needles (right and left), needle Cooper, Dufo needle, vascular clamps for temporary arrest of blood flow in the vessel: fenestrated Potts clamp, L-shaped Blalock vascular clamp, Doliotti vascular clamp, Geifner vascular clamp, Satinsky vascular clamp, Blalock vascular clamps. Suture material (silk, polypropylene, lavsan, fluorolone on atraumatic needles).
Stop bleeding in a wound. The exercise is performed during subsequent operations, vessels are found in the subcutaneous tissue when creating an access (Fig. 62). The surgeon captures the vessel with the surrounding tissues with a Billroth hemostatic forceps and bandages it with a ligature. At the same time, the interaction of the hands of the surgeon and the assistant is worked out. The command to remove the clamp is given to the assistant by the surgeon. After removing the hemostatic clamp, the surgeon tightens the tied knot and ties a second fixing knot. The ligation of the main vessel can be performed using a Deschamp or Cooper ligature needle (Fig. 63). In case of traumatic damage to the main vessel and the inability to suture the vessel, the vessel is tied up to stop the bleeding. Also, in order to stop bleeding in the region of blood supply of the main vessel, the vessel is ligated throughout. Indications for ligation of the main vessel throughout occur when the vessel is located in an anatomically difficult place (for example, with bleeding from the gluteal vessels or arrosive bleeding in a purulent wound).
Venesection is a surgical operation in which the saphenous vein is isolated, opened and inserted into the lumen of the catheter for prolonged infusion therapy.
Indications. Traumatic, hemorrhagic and burn shock, the need for intensive infusion therapy.
Access. The saphenous veins of the elbow bend (Fig. 64), the great saphenous vein of the thigh in the femoral triangle and on the anterior surface of the inner ankle, and the external jugular vein on the neck are used.
Anesthesia. Local anesthesia, 1% solution of novocaine, lidocaine.
Operation technique. A hemostatic tourniquet is applied proximal to the operation area. Subcutaneous tissue is infiltrated with novocaine. A skin incision over the vein is 3-4 cm long. Using a curved Billroth hemostatic clamp, the vein is isolated from the subcutaneous tissue for 2 cm, slightly lifted and two silk ligatures are passed under the vein (Fig. 65).
The distal ligature is immediately tied, the vein is switched off from the bloodstream. Using the tied ligature as a holder, the lumen of the vein is opened with vascular scissors at an angle of 45°. A plastic standard catheter is inserted into the lumen of the vein, a proximal ligature is tied, which fixes the catheter in the lumen of the vein. Sutures are placed on the skin, a catheter is tied to one of them.
Vascular suture
A vascular suture is a surgical technique for connecting the tissues of blood vessels.
Requirements for a vascular suture (principles):
1. Along the suture line, the vessels to be sutured should be in contact with homogeneous layers - intima with intima, muscle layer with muscle layer, adventitia of one vessel with a similar cover of another vessel. It is unacceptable that the muscular coat or adventitia cover get into the lumen of the sutured vessels. They, like exfoliated and non-fixed intima, can be the cause of the formation of a blood clot.
2. Atraumatic - careful handling of intimacy. The convergence of the stitched vessels should occur only due to the natural elasticity and stretching of their walls. Overstretching leads to rupture of the intima or the entire thickness of the vascular wall already during the operation and ends with unstoppable bleeding or thrombosis. Subsequent overstretching can also cause necrosis of the vessel walls.
3. The suture material should not protrude into the lumen of the vessel to avoid thrombosis.
4. Tightness - when applying a vascular suture, there should be no leakage of blood between its stitches.
5. The vascular suture should not lead to a change in the lumen of the vessel or its deformation and narrowing. This condition is necessary for normal blood flow at the junction of the vessels.
6. When suturing, uniform stitches should be achieved, both in width (1-2 mm from one another) and in distance from the edge of the vessels (1 mm). With pathologically altered walls and suturing of vessels of large diameter, it is necessary to capture more tissue in the seam and it is permissible to increase the distance between individual stitches.
7. The caliber of the vessel and the properties of its wall determine the choice of the diameter of the thread and needle. For suturing the aorta, 3/0 threads are used, for its large branches - 4/0, for the femoral, popliteal, brachial and carotid arteries - 5/0, for the arteries of the lower leg and forearm - 6/0, for large veins - 5/0, for coronary arteries - 7/0 and 8/0, for finger replantation - 10/0.
8. To apply a reliable vascular suture, special tools are used - vascular clamps, tweezers, needle holders and scissors.
9. In children and adolescents, the circular vascular suture should be nodular, since a continuous suture, especially a mattress suture, prevents the growth of the vessel and can subsequently lead to a narrowing of its lumen.
Tools. Dissector, Hepfner's vascular clamps (2 pcs.), Debecca's vascular clamps - "bulldogs", Potts fenestrated clamp, L-shaped Blalock clamp, Satinsky's lateral vascular clamp, atraumatic needles (Fig. 66a).
Suture material. For vessel suture, it is more expedient to use absorbable suture material (Polysorb, PDS, Maxon), for prosthetics - only non-absorbable synthetic threads (polyolefins, carolen, M-dec, goretex). The suture material must have a number of qualities (see topic 1), among which in the first place should be the unreactivity of blood and tissues to it and not wetted by blood.
Indications. Traumatic vascular injuries, reconstructive surgery for occlusive vascular diseases.
Exercise material. It is advisable to study the technique of manual vascular suture on one of the large arteries: the brachial or femoral. In addition, the exercise to master the vascular suture can be performed on the intestines of a rabbit or laboratory rats, fixed with a 4% formalin solution with the addition of alcohol and glycerol.
Types of vascular sutures:
1. Circular (circular):
a) continuous (twisting);
b) nodal.
2. Side:
a) continuous (twisting);
b) nodal:
c) transverse;
d) longitudinal.
3. Mechanical (superimposed by vasoconstrictors).
Side seam of the vessel. Sewing of a longitudinal wound (Fig. 666). Blalock clamps, bulldogs or Hepfner clamps are applied to the central and peripheral segments of the isolated artery to shut off the vessel from the bloodstream; for the same purpose, glove rubber tourniquets can be used. The anterior wall of the artery is dissected for 2-3 cm. Using an atraumatic needle with a nylon thread, a continuous suture is applied to the incision, achieving some inversion of the edges of the wound and their tight contact. The distance between the stitches of the seam should be no more than 1 mm. It should be remembered that the lumen of the vessel must not be narrowed by more than 1/3. The vessel wound can also be sutured with interrupted sutures.
Stitching of the transverse wound. After isolating the artery and applying clamps, its wall is cut across into 1/3 or 1/2 of the circle. The wound is sutured with a continuous mattress or nodal U-shaped suture.
Using a patch. With a significant narrowing of the co- T ^ vshchve ^ ^ E vessels in the area of the side seam suturing- | : * .Slotting can be
lead to narrowing of the lumen 666. Side seam of the court. In this case apply
sos yea plastic patch. as per
Various materials can be used - autovein, xenopericardium, synthetic tissues, etc. The use of an autovein is more physiological, but the use of a thin autovenous patch is undesirable, since in this case, under conditions of arterial blood flow, the probability of aneurysm development is high jfr^. / rhizmatic expansion
Ashcania. Therefore, preference is given to synthetic patches. PTFE patches have the best properties. The cut out patch should correspond to the size of the arteriotomy hole, the corners of the patch should be slightly rounded. The patch is sewn in with a continuous suture (Fig. 66c). The first suture is placed in the area of one of the corners of the patch, or two sutures are placed on opposite corners, subsequently performing 66c. Sewing in patch from those two seams towards each autovein DRU G U-
Circular seam of the vessel according to Carrel. Two vascular clamps (or tourniquets) are applied to the isolated artery, between which it is crossed across. Having brought the central and peripheral ends of the artery together, three fixation nodal or U-shaped sutures (sutures-holders) are applied around the circumference.
When the threads of the fixation sutures are pulled, the lumen of the artery acquires a triangular shape. Between the fixation sutures, the vessel wall is sutured with frequent stitches of a continuous suture (Fig. 66d, fragment o). First, the posterior third of the vascular wall is sutured, and then, turning the artery with the help of threads of fixed sutures, the lateral ones. The vessel wall is often sutured with continuous mattress or interrupted U-shaped sutures.
Modifications of the vascular suture. The technique of L. I. Morozova (used in surgery of medium and large vessels). Instead of three stitches-holders, two are used. The role of the third holder is assigned to the main thread. A twist suture is applied to one (anterior) wall of the vessel, after which the clamps with the vessel are turned 180° and the other semicircle of the vessel is sutured.
The technique of V. R. Braitsev - M. Briand - F. Zhaboulet. The ends of the vessel are connected using nodal, U-shaped eversion seams. It is used to connect vessels in children, since as the child grows, there is no narrowing of the anastomosis zone.
Modified by A. A. Polyantsev. Use not nodal, but U-shaped seams-holders.
Method of vascular suture of E. N. Meiyulkin on large vessels. In 1956, E. N. Meshalkin, when performing a cavapulmonary anastomosis, proposed a technique for applying a U-shaped eversion suture, which consists in the following: after isolating the vessel, taking it on rubber holders and applying clamps, the vessel is cut between them, a natural diastasis is formed between segments of the dissected vessel, which increases even more when the pathological area is excised. If, with a slight effort, it is possible to bring the segments of the vessel together, then the injection of an atraumatic needle (it is better to start from right to left) is performed from the outside inward, with an indent of 1-2 mm from the edge of the upper or lower segment of the vessel. The same needle is punctured from the inside to the outside of the opposite segment. The thread is pulled in such a way that its section, which will be used to suture the back lip, has the maximum length. The other end of the thread is taken to the clamp. A needle with a long thread is injected from the outside to the inside, after which stitches of the seam are applied with a simultaneous injection from the inside to the outside and from the outside to the inside
Rice. 66g. Vascular sutures: a, b - according to Carrel with sutures-holders according to Polyantsev (a - suturing-holders, stretching of the holders, b - the imposition of a bypass seam between the holders); in - according to Littman (imposition of a continuous mattress suture); g - according to Zhabula - Braitsev (imposition of separate U-shaped seams); e - according to Meshazhin on large vessels (explanation in the text)
through all layers of the opposite segment to the end of the posterior lip (Fig. 66d, fragment e). The stitches should be laid parallel at 1-2 mm intervals from each other at an equal distance of puncture and puncture from the edges of the vessel. Diastasis of segments of the vessel is preserved. Upon reaching the opposite (left) section of the posterior lip, the thread breaks out. After that, the surgeon gradually tightens the suture with both threads, and the assistant brings the segments of the vessel together with the help of clamps that compress the vessel. After tightening, a slightly wavy line is formed, the intima fits snugly to the intima, the threads are usually not visible in the lumen. To secure the suture of the posterior lip of the anastomosis, U-shaped handles are applied on both sides, which are connected to the main suture. This prevents loosening of the suture and does not compromise its tightness against the posterior lip of the anastomosis. The anterior lip of the anastomosis is sutured through all layers of the adjacent segments. The lower clamp is removed first, and then the upper clamp, and blood flow is restored.
Thus, the main features of the imposition of a U-shaped continuous eversion seam by E. N. Meshalkin are as follows:
1. The suture is applied to the posterior lip of the anastomosis from the inner surface of the vessel through all layers with the injection and removal of the needle towards the intima.
2. Preliminary sutures are not applied.
3. The suture is applied with constant diastasis of the sutured segments of the vessel.
4. To prevent relaxation of the thread and leakage of the anastomosis, U-shaped sutures-holders are applied after tightening the suture on the posterior lip of the anastomosis, followed by tying the main suture with the thread.
Muscles, tendons, fascia, bones on the lower limb are involved in the formation of pits, canals, furrows, holes in which nerves, blood vessels, lymph nodes and vessels are located.
Lower limb girdle area
In the region of the girdle of the lower limb, a suprapiriform opening (foramen suprapiriforme) is distinguished; pear-shaped hole (foramen infrapiriforme); obturator canal (canalis obturatorius); muscle gap (lacuna musculorum); vascular lacuna (lacuna vasorum).
Suprapiriform foramen (foramen suprapiriforme)(fig. 102 (3)) and piriform opening (foramen infrapiriforme)(Fig. 102 (4)) are located above and below the piriformis muscle (m. piriformis) in the large sciatic foramen. Arteries, veins and nerves pass through the suprapiriform and subpiriform openings.
obturator canal(Fig. 102 a) has a length of 2-2.5 cm, is located in the upper part of the obturator foramen (5) between the obturator groove of the upper branch of the pubic bone and the upper edge of the internal obturator muscle and the obturator membrane. In the obturator canal are the vessels and nerves of the same name. The obturator canal connects the pelvic cavity with the medial region of the thigh.
Muscular lacuna (lacuna musculorum) and vascular lacuna (lacuna vasorum)(Fig. 109 a) are formed as a result of the division of the space under the inguinal ligament by a section of the fascia of the iliopsoas muscle, which is called iliopectineal arch (arcus iliopectineus)(one). This arch fuses with the inguinal ligament (4) from above, and with the periosteum of the pubic bone (5) from below. Outside of the arcus iliopectineus is a muscular lacuna (lacuna musculorum) (2); the iliopsoas muscle (musculus iliopsoas) and the femoral nerve (nervus femoralis) pass through it. Inward from the arcus iliopectineus is the vascular lacuna (lacuna vasorum) (3), in which the femoral artery (arteria femoralis) (laterally) and the femoral vein (vena femoralis) (medially) are located.
Through muscular and vascular lacunae, the cavity of the large pelvis communicates with the anterior region of the thigh.
Thigh area
In the thigh area, the femoral triangle (trigonum femorale) is distinguished; subcutaneous fissure (hiatus saphenus); femoral canal (canalis femoralis) (in case of femoral hernia); iliopectineal groove (fossa) (sulcus (fossa) iliopectinea); femoral groove (sulcus femoralis); adductor canal (canalis adductorius).
Femoral triangle (trigonum femorale)(Fig. 104 a) stands out on the front of the thigh. Its borders: inguinal ligament (ligamentum inguinale) (14) (top), tailor muscle (musculus sartorius) (1) (laterally) and the edge of the long adductor muscle (musculus adductor longus) (11) (medially).
Hypodermic fissure (hiatus saphenus)(Fig. 109 b (3)) is located below the medial part of the inguinal ligament (7) and is represented by a small depression covered by a portion of the superficial leaflet of the wide fascia of the thigh; this section of the fascia is called cribriform fascia (fascia cribrosa). The subcutaneous fissure is limited sickle-shaped edge (margo falciformis) (4) which has upper horn (cornu superius) (5) and lower horn (cornu inferius)(6). In front of the lower horn is a large saphenous vein (vena saphena magna) (8) at its confluence with the femoral vein. As a rule, a lymph node is located in the subcutaneous fissure.
Femoral canal (canalis femoralis)(normally absent, but formed when a femoral hernia occurs) is located in the medial part of the vascular lacuna (lacuna vasorum). It has 3 walls: 1 anterior wall formed by the inguinal ligament (ligamentum inguinale) and the upper horn of the sickle-shaped edge (cornu superius margo falciformis) fused with it; 2 back wall represented by a deep leaf of the wide fascia of the thigh (9); 3 lateral wall formed by the femoral vein (10). From the side of the abdominal cavity, the femoral canal has internal femoral ring (anulus femoralis)(channel inlet); its borders: from the medial side lacunar ligament(11), from the lateral side - the femoral vein, from above - the inguinal ligament, from below - the pectineal ligament (lig.pectineale); outer (exit) hole the femoral canal is limited by a crescent-shaped margin (margo falciformis) (4).
Iliopectineal groove (fossa) (sulcus iliopectineus, seu fossa iliopectinea)(Fig. 104 a, c) is located in the upper part of the femoral triangle and is represented by a depression between the comb muscle (10) (medially) and the iliopsoas muscle (15) (laterally). At the bottom of this groove (fossa) are the femoral artery, vein and saphenous nerve.
Femoral groove (sulcus femoralis) is the distal continuation of the iliopectineal sulcus. Its walls are formed by the long adductor and large adductor muscles (musculus adductor longus) (11) (et musculus adductor magnus) (13) (medially) and the wide medial muscle of the thigh (musculus vastus medialis) (5) (laterally). In front, the femoral groove is covered by the sartorius muscle (musculus sartorius) (1).
Leading canal (canalis adductorius)- continuation of the femoral groove downwards (Fig. 104 c). It has three walls: 1 lateral wall, formed by the medial broad muscle of the thigh (musculus vastus medialis) (5); 2 medial wall, represented by a large adductor muscle (musculus adductor magnus) (13); 3 front wall, which is a section of the wide fascia of the thigh, passing from the medial wide muscle of the thigh to the large adductor muscle. This section of the fascia looks like a dense tendon plate and is called lamina vastoadductoria(16).
The leading channel has 3 holes: 1 top hole limited by the same formations as the walls of the adducting channel; 2 bottom hole(fig. 101) is presented tendon gap (hiatus tendineus)(5) in the tendon of the large adductor muscle (4); 3 front opening- a small gap in the anterior wall of the adductor canal, through which the descending artery of the knee and the saphenous nerve exit. The femoral artery and vein pass through the canal.
knee area
An important formation in the knee area is the popliteal fossa (fossa poplitea) (Fig. 104 b).
Popliteal fossa (fossa poplitea)(17) is located in the back of the knee (regio genus posterior), has the shape of a rhombus. From above, this fossa is bounded by the semimembranous muscle (musculus semimembranosus) (9) (medially) and the biceps femoris (musculus biceps femoris) (6, 7) (laterally). From below, the boundaries of the popliteal fossa are represented by the medial (18) and lateral (19) heads of the gastrocnemius muscle (musculus gastrocnemius). The bottom of the popliteal fossa is formed by the popliteal surface (facies poplitea) of the femur and the capsule of the knee joint. The popliteal fossa contains the popliteal vessels and the tibial nerve.
Calf area
In the region of the lower leg, 3 canals are distinguished: 1 - ankle-popliteal canal (canaliscruropopliteus); 2 - superior musculoperoneal canal (canalis musculoperoneus superior); 3 - lower musculoperoneal canal (canalis musculoperoneus inferior).
Ankle-popliteal canal (canalis cruropopliteus) starts from the lower corner of the popliteal fossa. The channel has front and back walls. The anterior wall is formed by the posterior tibial muscle (musculus tibialis posterior), the posterior wall of the ankle-popliteal canal is represented by the soleus muscle (musculus soleus). The ankle-popliteal canal has 3 openings: 1 - inlet (upper), 2 - anterior, 3 - outlet (lower). Upper (inlet) hole bounded anteriorly by the popliteal muscle (musculus popliteus), posteriorly by the tendinous arch of the soleus muscle (arcus tendineus musculi solei). front opening located in the upper third of the interosseous membrane (membrana interossea). Bottom (exit) hole located in the medial part of the distal third of the lower leg, where the soleus muscle passes into the calcaneal (Achilles) tendon. The tibial artery, veins, and nerve are located in the ankle-popliteal canal.
Superior musculoperoneus canal (canalis musculoperoneus superior) begins behind the head of the fibula. The canal is located between the lateral surface of the fibula and the long peroneal muscle (musculus peroneus longus). The common peroneal nerve passes through the superior musculoperoneal canal.
Inferior musculoperoneus canal (canalis musculoperoneus inferior) begins in the middle third of the lower leg and is, as it were, a branch of the ankle-popliteal canal. The channel has 2 walls: 1 anterior, formed by the fibula (fibula (perone)), and 2 back, represented by the long flexor thumb foot (musculus flexor hallucis longus) and posterior tibial muscle (musculus tibialis posterior). The peroneal artery and veins pass through the inferior musculoperoneal canal.
Foot area
On the plantar surface of the foot, 2 grooves are distinguished: 1 - medial plantar groove (sulcus plantaris medialis) and 2 - lateral plantar groove (sulcus plantaris lateralis).
Medial plantar sulcus limited to the short flexor of the toes (musculus flexor digitorum brevis) and the medial group of muscles of the sole of the foot.
Lateral plantar sulcus (sulcus plantaris lateralis) located between the short flexor of the toes (musculus flexor digitorum brevis) and the lateral group of muscles of the sole of the foot.
In the medial and lateral plantar sulci are plantar vessels and nerves of the same name.
outdoor landmarks
On the foot, in addition to the ankles, you can feel under them, on both sides, calcaneus, the tubercle of which - sustentaculum tali - is recognized under the medial malleolus (at a distance of 2.5 cm downwards from it) in the form of a narrow transverse protrusion. On the inner edge of the groan at a distance of 4 cm downwards and anterior to the ankle, the navicular bone with its tuberosity is determined. Posterior to the scaphoid, between it and the ankle, it is possible to determine the head of the talus, separated from the navicular by a transverse fissure.
Anterior to the navicular bone, at a distance of about 3 cm from it, the base of the 1st metatarsal bone is less clearly palpable, then the head of this bone, followed by the first phalanx of the thumb.
Along the outer edge of the foot, one can feel the calcaneus, on which, at a distance of 2.5 cm downward and somewhat anterior to the lateral malleolus, a narrow bone protrusion can be determined: tendon m lies anterior to it. Peroneus brevis, posteriorly - tendon m. Peroneus longus. Anterior to the trochlea, on the outer edge of the table, a sharply protruding tuberosity is determined - tuberositas ossis metatarsalis.
Immediately outside of the tendon of the long extensor of the thumb, you can feel the pulse on a. Dorsalis pedis.
Rear of the foot
In the superficial layers there is a venous plexus - a venous network of the rear of the foot from the medial part of which the great saphenous vein arises, from the lateral part the small saphenous vein. Distal to the venous network is located, connected to it by the venous arch of the rear of the foot, where the dorsal metatarsal veins flow.
The skin of the region is supplied with branches nn. Saphenus, suralis, peroneus superficialis profundus. Under the skin, between the heads of the metatarsal bones, lie synovial
bags: three medial ones are always present, the fourth one is inconstant.
Own fascia of the region is a continuation of the fascia of the lower leg. Together with the deep fascia, which is located on the metatarsal bones and dorsal interosseous muscles, it forms a sac that contains the long extensor tendons, the muscle parts and the short extensor tendons.
With u and l and I long extensors pass each in its vagina under the reticunaculum mm. Extensorum inferius. Of these, the tendon m/ tibialis anterior is attached to the medial sphenoid and 1 metatarsal bones; the remaining tendons go to the phalanges of the fingers. The second layer contains m. Exstensor digitorum brevis m. Extensior hallucis brevis.
The vascular bundle - the nerve bundle of the rear of the moan is made up of
a. dorsal artery with two accompanying veins and n peroneus profundus. The artery passes outward from the tendon m. Extensjr hallucis longus being covered in the distal by the tendon of the short extensor of the thumb. Before reaching the first intermetatarsal space, the dorsal artery gives off the arcuate artery passing under the short extensor of the fingers, and then in the intermetatarsal space they split into two branches: 1) a. metatarsa dorsales 1, which serves as a continuation of the trunk, and 2 ramus plantaris profundus, passing to the sole through the first intertarsal gap and participating in the formation of the arcus plantaris. N. peroneus profundus lies medially from the artery, but often also outwards from it. The nerve gives off a branch to the short extensor of the fingers and sensitive branches to the skin of the first interdigital space and the sides of the I and II fingers facing each other
The skin of the sole is dense and thick, the subcutaneous tissue is highly developed and permeated with powerful fibrous bundles emanating from the plantar aponeurosis. Between the fiber and the aponeurosis, there are several synovial bags in the region of the calcaneal tubercle and at the level of the first and fifth metatarsophalangeal joints.
The plantar aponenrosis, containing strongly pronounced tendon bundles, extends from the calcaneal tuber to the heads of the metatarsal bones. At the level of these heads, the transverse and longitudinal fibers of the plantar avoneurosis form comssural foramina, similar to those found in the palm of the hand.
Fascial beds and canals of the sole. The sub-neurotic space of the sole is divided by partitions and deep (interosseous) fascia into four receptacles or beds, for the muscles of the sole, going deep from the aponeurosis. The septa originate in the area of the sulcus planraris medial and connect the plantar aponeurosis with the long ligament of the sole; they are best expressed in the anterior tarsus. The deep bed contains the interosseous muscles, the other three belong to the plantar muscles; of these, the medial bed contains the muscles of the thumb, the lateral - the muscles of the thumb, the middle - the rest Thus, the middle bed contains the most superficial layer, deep
fascia of the sole. The medial bed is filled with b. flexor chalicis brevicis and tendon m. flexor chalicis longus. The lateral bed is occupied by the muscles of the thumb: m. abductor and flexor digital mini brevis.
The lateral and medial beds of the sole are usually isolated, while the middle bed communicates with the deep bed of the lower leg through three channels that pass one into the other. The plantar canal connects directly to the middle bed, which proximally passes into the calcaneal canal; the latter passes into the ankle canal, which communicates with the deep bed of the posterior region of the leg.
The plantar canal is located in the deep layers of the tarsus, under the arch of the foot. The walls of the plantar canal are formed: from the sides - by fascial septa, from above - by a long ligament of the sole, from below - by the deep fascia of the sole, located between the short flexor of the fingers and the square muscle of the sole. The contents of the plantar canal are m. Quadratus plantaris, tendons of the long flexors (fingers and thumb) and both neurovascular bundles of the sole (lateral and medial). Distally, the plantar canal leads to the cellular fissure of the middle fascial bed.
Vessels and correct soles. Of the two plantar arteries a. plantaris medialis is less developed and runs along the medial septum.a. plantaris lateralis - a large terminal branch of a. tibialis posterior. It passes between m. flexor digitorum brevis and m. quadratus plante, then along the lateral septum to the base of the 5th metatarsal, at the level of which they are directed inwards, forming an arc - arcus plantaris. The latter is located under the oblique head of the adductor muscle of the thumb and connects to the deep plantar branch of the dorsal artery of the table. From the arc depart a metatarse plantaris from which arise a. digitalis plantaris.
The nerves accompany the arteries of the same name. Branches depart from the nerves to the muscles of the sole and metatarsal bones, as well as the plantar digital nerves.
On the back surface of the fingers, the skin is thin, on the plantar it is dense and developed in the form of pillows. the dorsal aponeurosis, into which the extensor tendons pass, is attached by the lateral parts to the bases of the terminal phalanges, and by the middle parts to the bases of the middle phalanges.
The tendons of the long flexor are attached to the bases of the terminal phalanges, the tendons of the short flexor are pierced by the tendons of the long flexor and are attached to the bases of the middle phalanges. On each finger, the tendons of both flexors are enclosed in a common synovial sheath.
Unlike the hand, the synovial sheaths of the 1st and 5th toes do not form such long synovial sacs that run along the entire hand and end on the forearm. On all fingers of the moan, the synovial sheaths of the flexor tendons end blindly, approximately at the level of the heads of the metatarsal bones.
Vessels and nerves run on the dorsal and plantar surfaces of the fingers, closer to their lateral side. The plantar vessels are much more developed than the dorsal ones. The dorsal arteries are branches of the dorsal metatarsal arteries, with the exception of two arteries supplying the surfaces of fingers 1 and 2 facing each other and arising from the dorsal artery of the groans. Dorsal nerves (10 according to the number of lateral sides of the fingers) arise: the first 7 (for 3.5 medial fingers) - from n. pyroneus superftsmalis and the last Z (for 1.5 lateral fingers) - from n. sualis The sides of the first two fingers facing each other receive branches and out. Pyroneus profundus.
The plantar digital arteries arise from the plantar metatarsal arteries at the fingertips and form networks. Plantar ridges (10) arise: the first 7 for 3.5 medial fingers) from n. plantaris medialis, last 3 (for 1.5 lateral fingers) - from n. plantaris lateralis.
Leather dense, immobile.
Subcutaneous tissue dense, lobed, reaches its greatest thickness at the fulcrum. Permeated with dense connective tissue bundles connecting the skin with the underlying aponeurosis of the sole.
Own fascia The sole of the sole in the middle section is represented by the plantar aponeurosis (aponeurosis plantaris), which extends from the calcaneal tuberosity to the heads of the metatarsal bones. The aponeurosis consists of longitudinally and transversely running tendon fibers. At the level of the heads of the metatarsal bones, the transverse and longitudinal fibers of the aponeurosis form commissural openings. From the edges of the plantar aponeurosis, the inner and outer fascial intermuscular septa depart. The internal intermuscular septum is attached to the calcaneus, scaphoid, medial sphenoid and I metatarsal bones; the outer one is fixed to the fifth metatarsal bone. They divide the entire space under the plantar aponeurosis into three sections: medial - or the bed of the muscles of the first finger, lateral - or the bed of the muscles of the fifth finger and the median.
In the medial box the following muscles lie: the muscle that abducts the first finger (m. abductor hallucis), short flexor of the first finger (m. flexor hallucis brevis) and tendons of the long flexor of the first finger (m. flexor hallucis longus).
The lateral muscle group is represented by: the muscle that removes the little finger (m. abductor digiti minimi), flexor muscle of the little finger (m. flexor digiti minimi), muscle that opposes the fifth finger (m. opponens digiti minimi).
In the median fascial bed immediately below the aponeurosis are located: a short flexor of the fingers (m. flexor digitorum brevis), square muscle of the sole (m. quadratus plantae) and tendon of the long flexor of the fingers (m. flexor digitorum longus) with worm-like muscles starting from them (mm. lumbricales). The oblique and transverse heads of the adductor I finger are located deeper. (m. adductor hallucis),, obliquely crosses the sole of the tendon of the long peroneal muscle.
Plantar interosseous muscles are enclosed by interosseous fascia in a separate bed.
The blood supply and innervation of the plantar surface of the foot is carried out by the medial and lateral plantar vessels and nerves.
Between the muscle beds, 2 grooves are distinguished: medial (sulcus plantaris medialis)(located between the short flexor of the fingers and the muscles of the first finger) and lateral (sulcus plantaris lateralis)(located between the short flexor of the fingers and the muscles of the little finger). The vessels and nerves of the sole pass through them.
In the ankle canal, the posterior tibial artery and tibial nerve divide into branches: medial and lateral plantar vessels and nerves that pass to the sole into the calcaneal canal (located between the calcaneus and the muscle that abducts the first finger). After passing through the calcaneal canal, the vessels enter the medial and lateral plantar sulci.
Medial plantar vessels and nerve (a. plantaris medialis et n. plantaris medialis) are directed to the medial plantar sulcus.
Lateral plantar vessels and nerve (a. plantaris lateralis et n. plantaris lateralis) first they are located in the median bed between the short flexor of the fingers and the square muscle of the sole, then they pass into the lateral plantar groove. At the level of the heads of the metatarsal bones, the lateral plantar artery passes again into the median bed, where it anastomoses with the deep plantar branch from the dorsal artery of the foot, and participates in the formation of the plantar arch. (arcus plantaris). Plantar metatarsal arteries arise from the plantar arch (aa. metatarseae plantares), which give rise to the common plantar digital arteries (aa. digitales plantares communes), the latter are divided into their own plantar digital arteries (aa. digitales plantares propriae)(own digital artery to the outer edge of the little finger departs directly from the lateral plantar artery).
projections
Medial plantar neurovascular bundle projected along a line drawn from the middle of the inner half of the width of the sole to the first interdigital space.
Lateral plantar neurovascular bundle projected along a line drawn from the middle of the width of the sole (or from the middle of the line connecting the tops of the medial and lateral malleoli) to the 4th interdigital space.
Cellular spaces
In the middle fascial bed, the following cellular spaces are distinguished.
Subaponeurotic cellular gap - between the plantar aponeurosis and the short flexor of the fingers. Proximally closed, distally passes into the pancreas of the sole through the commissural openings.
Superficial cellular gap - between the short flexor of the fingers and the tendons of the long flexor of the fingers. Connected proximally with the plantar and calcaneal canals, distally - with interdigital tissue.
Deep cellular gap - between the tendons of the long flexor of the fingers and the muscle that leads to the first finger. Associated with fiber plantar canal and interdigital spaces.
The medial and lateral fascial beds do not contain a large accumulation of fiber and do not have pronounced cellular gaps.
Ways of distribution of purulent streaks from the middle fascial bed
On the dorsal surface of the foot along the deep plantar branch of the dorsal artery of the foot and along the worm-like muscles.
In the pancreas of the sole through the commissural openings of the plantar aponeurosis.
In the posterior fascial bed of the leg. The middle bed communicates with the deep bed of the lower leg through three channels. The plantar canal is connected to the middle bed, which proximally passes into the calcaneal; the latter passes into the ankle, communicating with the deep bed of the posterior region of the lower leg.
In the medial bed of the sole along the tendon of the muscle that leads to the first finger.
In the lateral bed of the sole along the tendon of the 5th finger from the long flexor of the fingers.