Innervation of the right leg. Functional anatomy of the peroneal nerve

The term innervation refers to the set of nerves connecting the limbs or certain organs to the central nervous system. Innervation of the lower extremities is carried out using the lumbar and sacral plexuses.

With certain disturbances in the activity of the nerves of the lower extremities, serious diseases can develop. Let's look at the most common of them.

Located in the lumbar plexus and is responsible for the innervation of the thigh muscles and the sensitivity of the skin on the thigh, leg and foot.

Damage to this nerve occurs in the retroperitoneal space (the junction with the inguinal bandage). Diseases are mainly diagnosed after 40 years in women, due to physiological characteristics. In some cases, wear and tear of the thigh muscles occurs, which leads to nerve damage.

Neuropathy

Neuropathy forms at the lumbar level. The disease is caused by pinching of the femoral nerve due to muscle spasm or hematoma. Causes:

Fiber damage.
Excessive loads.
Bleeding.
Benign or malignant formations.
Diseases of the circulatory system.
Poisoning.

The process proceeds secretly, but when complications occur, pain is noted, the skin at the site of the lesion acquires a purple tint, and swelling is observed. Neuropathy is diagnosed by palpation and visual examination.

Therapy includes the following stages:

Taking medications for inflammation.
Massage and special gymnastics.

Neuritis

Inflammation of the peripheral nerve. Damage to nerve fibers hip joint may be caused by a number of factors:

Fiber pinching.
Accumulation of blood after injury.
Complication after surgery.

The disease has the following symptoms:

The tumor is dark pink.
Moving a limb is problematic.
Pain when moving.

Femoral nerve neuritis often develops into a chronic disease. For diagnosis, it is necessary to take a functional test to determine the degree of the disease and the nature of the damage to the nerve fiber. The neurologist develops complex therapy that is aimed at eliminating the cause of the disease, and not at relieving pain.

Neuralgia

A pathological disease of the peripheral femoral nerve, in which a person complains of sharp and severe pain. This condition is caused by irritation of nerve endings in a specific area. Neuralgia is caused by a herniated disc, which grows and puts pressure on the nerve endings, resulting in pinched fibers.

Symptoms:

Discomfort in the thigh area.
Pain.
Burning.
Increased body temperature.
Painful sensations radiate to the groin and other parts of the body.

For diagnosis, an initial examination is performed and a CT scan is prescribed. Anti-inflammatory drugs, vitamins and special exercises are used as therapy.

Obturator nerve

This nerve provides sensation inner surface hips. Pathological conditions include neuropathy.

Etiology:

During fractures of the pelvic and hip bones, with damage to the obturator nerve.
Benign and malignant formations.
Recovery after surgery.

Weakness in the legs.
Problematic movement.
Decreased sensitivity.

For diagnosis, a thorough examination of the pelvic and intestinal organs is performed. Also research using CT and MRI. Treatment is carried out based on the results of the examination.

Sciatic nerve

The longest and largest mixed nerve, consisting of motor, sensory and autonomic fibers.

Pathologies of the sciatic nerve can be divided into:

– inflammation (neuritis).
Sciatica is pain throughout the entire nerve.

Diagnosis requires examination by a traumatologist, neurologist, and in some cases, a neurosurgeon. Therapy is selected depending on the examination results and is aimed at eliminating the cause of the disease.

Neuritis can be caused by the following reasons:

Infectious diseases.
Hypothermia.
Excessive loads.
Intervertebral hernia.
Spondylosis.
Osteocondritis of the spine.
Deformation or damage to the spine.
Purulent diseases.
Raynaud's or Lyme disease.

The disease manifests itself in the form of burning pain in back surface hips, and therefore active movements cannot be performed. As sciatica progresses, it can lead to complete immobility, since every movement causes severe pain to a person.

Sciatica

Divided into several types:

Musculoskeletal – lesions in the spine and legs.
Neuropathic – formed due to compression of the nerve plexuses.
Angiopathic – problems with blood circulation in nerve fibers.
Mixed – affects several factors at once.

The clinical symptoms of inflammation and sciatica are similar.

Prevention

In order to prevent diseases, you should follow the following recommendations from specialists:

Increase physical activity.
News healthy image life.
Do not be nervous.

If you have the slightest problem with your lower extremities, you should immediately contact a medical facility.

What to do (video)

Nerve diagram lower limb:
1 - iliohypogastric nerve;
2 - obturator nerve;
3 - ilioinguinal nerve;
4 - femoral nerve;
5 - genital-femoral nerve;
6 - lateral cutaneous nerve of the thigh;
7 - sciatic nerve;
8 - posterior cutaneous nerve of the thigh;
9 - common peroneal nerve;
10 - tibial nerve;
11 - medial cutaneous nerve of the calf;
12 - deep peroneal nerve;
13 - saphenous nerve;
14 - superficial peroneal nerve;
15 - lateral cutaneous nerve of the calf;
16 - sural nerve;
17 - medial and lateral plantar branches

Short branches include:
muscular branches (rr. musculares) innervating quadratus muscle thighs, superior and inferior gemellus, piriformis and obturator internus;
superior gluteal nerve (n. gluteus superior), which innervates the tensor fascia lata thighs, gluteus medius and minimus;
inferior gluteal nerve (n.
gluteus inferior), heading to the gluteus maximus muscle;
the genital nerve (n. genitalis) is classified as mixed. Sensory fibers innervate the skin of the perineum and external genitalia, and motor fibers innervate the muscles of the perineum.

Long branches include:
posterior cutaneous nerve of the thigh (n. cutaneus femoris posterior), which is sensitive and goes to the skin of the posterior surface of the thigh;
sciatic nerve (n. ischiadicus), which is a mixed nerve and is the largest nerve in the human body. Many branches extend from it, heading to the muscles of the posterior thigh. The nerve itself descends to the upper part of the popliteal fossa, where it divides into the tibial and peroneal nerves.

The tibial nerve (n. tibialis) runs along the posterior tibial artery between the deep and superficial flexors of the tibia and behind the medial malleolus of the tibia it enters the plantar surface of the foot.

In the region of the popliteal fossa, the tibial nerve gives off the following branches:
medial cutaneous nerve of the calf (n.
cutaneus surae medialis) is directed to the skin of the posteromedial surface of the leg. IN lower section The lower leg unites with the lateral cutaneous nerve of the calf. Together they form the sural nerve (n. suralis) (Fig. 276), passing behind the lateral malleolus and innervating the lateral parts of the dorsum of the foot;
muscular branches (rr. musculares) innervate the muscles of the posterior surface of the leg.

In the lower leg, the tibial nerve gives off the following branches:
medial calcaneal branches (rr. calcanei medialis) are directed to the skin of the medial parts of the heel;
muscular branches (rr. musculares) innervate the deep layer of the posterior group of muscles of the leg.

On the surface of the foot, the tibial nerve is divided into medial and lateral plantar branches (rr. plantares medialis et lateralis), which are mixed and follow the same direction as the plantar arteries. Sensitive fibers of the medial plantar nerve are directed to the skin of the medial part of the sole of the foot and to the skin of the I, II, III, IV fingers.

Motor fibers are directed to the flexor digitorum brevis muscle, the abductor hallucis muscle and the 1st-2nd lumbrical muscles.
The motor fibers of the lateral plantar nerve innervate the flexor little toe brevis, abductor little toe, adductor hallucis, quadratus plantae, interosseous, and lumbricals 3–4.

The common peroneal nerve (n. fibularis communis) is a mixed nerve and in the lateral part of the popliteal fossa is divided into the superficial and deep peroneal nerves.

The main branches of the common peroneal nerve are:
lateral cutaneous nerve of the calf (n. cutaneus surae late-ralis), heading to the skin of the posterolateral parts of the leg and uniting with the medial cutaneous nerve of the calf;
superficial peroneal nerve (n. fibularis superficialis), which is mixed. Its sensory fibers innervate most of the skin on the dorsum of the foot, and motor fibers innervate the long and short peroneal muscles;
deep peroneal nerve (n. fibularis profundus), following along the tibial artery.
Its sensitive branch gives off many branches into the skin of the dorsum of the foot in the area of the first interdigital space. Motor fibers innervate the anterior group of muscles of the lower leg and the muscles of the dorsum of the foot.

The foot is the most distal part of the human lower limb. This means that it is furthest from the center of the body. It is the feet that bear the entire load of the body's weight. Therefore, such a seemingly small part of the body has a very thoughtful structure. Read more about the anatomy, blood supply and innervation of the foot later in the article.

Topographic anatomy

The structure of any structure human body should be considered gradually. Therefore, before moving on to the anatomy of the innervation of the foot, it is necessary to disassemble its other parts. The foot, like any other musculoskeletal formation in the human body, consists of the following parts:

bone frame;
joints;
striated muscles;
vascular formations: veins, arteries, capillaries;
nerves.

Bone frame

To fully understand the innervation and blood supply of the foot, one must understand what major bony structures it consists of. After all, large nerves and blood vessels are predominantly located along the bones and have similar names.

There are three areas on the foot:

tarsus;
metatarsus;
phalanges of fingers.

The tarsal region is located most proximally, that is, directly under the ankle joint. The line that demarcates these two formations is also the upper edge of the human foot. This line runs along the posterior edge of the heel bone.

The tarsus contains two rows of small bones. The first row, which is located closer to the edge of the foot, consists of the talus and calcaneus. They are larger. In the second row, which is closer to the metatarsus, there are five bones at once, placed in two more rows. The first is represented by four bones: three wedge-shaped and one scaphoid. The second row contains only one cuboid bone.

The metatarsal part of the foot is located in the middle between the other two sections. It consists of five bones of approximately the same shape and size. Each of them includes three parts: head, body and base.

The phalanges of the fingers consist of the smallest bones. Each phalanx includes three bones. The only exception is the big toe, which consists of only two bones. This finger is also called the first and is designated by the Roman numeral I. The little finger, accordingly, is designated by the number V.

Core muscles

The main task of the nerves involved in the innervation of the foot is aimed precisely at transmitting impulses to the muscle frame. After all, it is precisely due to the receipt of nerve impulses that muscle contraction is possible, and therefore, a person can walk.

There are five muscle groups in the foot:

lateral;
back;
front;
surface layer;
deep layer.

The lateral group includes the long and short peroneus muscles. Their contraction ensures abduction, outward rotation (pronation) and flexion of the foot.

The anterior group consists of the following muscles:

extensor hallucis longus, due to which it is possible to extend both the first toe and the foot as a whole by lifting its upper edge;
anterior tibial, which provides extension of the foot;
extensor digitorum longus, due to which it is possible to extend the second to fourth toes, as well as raise the outer edge and abduct it to the side.

The muscles of the superficial layer are involved in the formation of the Achilles tendon, which ensures movement in the ankle joint.

The deep layer of muscles consists of the flexor digitorum longus (provides external rotation of the foot and its flexion), the long flexor of the first toe (performs the function in accordance with the name), the posterior tibial muscle (flexion of the foot and adduction inwards).

Features of blood supply

The innervation of the foot and the course of the arteries in it are inextricably linked, since in most cases the artery, vein and nerve go in the same direction. Therefore, you should know the main vessels of the distal limbs. These include:

posterior tibial artery;
anterior tibial artery;
lateral plantar artery;
medial plantar artery;
dorsal artery of the foot.

The posterior and anterior tibial arteries are continuations of the popliteal artery.

The lateral and medial plantar arteries, true to their name, carry blood to the plantar part of the foot. The medial vessel has two branches: deep and superficial. The deep one carries blood to the muscle that abducts the big toe and the flexor digitorum brevis muscle. The superficial branch supplies blood only to the abductor pollicis muscle.

The lateral plantar artery supplies blood to most of the sole. At the level of the base of the metatarsus, it forms a plantar arch, from which many small branches extend to various structures of the foot. From this arch branch the plantar metatarsal arteries, which, in turn, give off branches called “perforating”.

From the plantar metatarsal artery at the level of the phalanges of the fingers, the plantar digital artery is formed, each of which is then divided into two own arteries.

The dorsal artery of the foot carries blood to the dorsum. It eventually divides into two branches: the first dorsal metatarsal artery and the deep plantar branch. The tarsal vessels also depart from it: lateral and medial. They carry blood to the lateral and medial surfaces of the foot, respectively.

Another branch of the dorsal vessel of the foot is the arcuate artery. From it, by analogy with the plantar vessels, the dorsal metatarsal arteries depart, which are divided into digital arteries.

Nerves of the dorsum of the foot

Let's start looking at the nerves of the most distal part of the limb with the innervation of the dorsum of the foot. But first you need to figure out what the external landmarks of this site are. The inner edge is limited by the tuberosity of the navicular foot, which is easy to palpate, especially in thin people. The tuberosity of the fifth metatarsal is easily visible at the outer border.

The innervation of the skin of the foot, namely its dorsal parts, is carried out by the following nerves:

saphenous nerve;
medial cutaneous dorsal nerve;
intermediate cutaneous dorsal nerve;
lateral dorsal cutaneous nerve.

The first three are branches of the superficial peroneal nerve, the last one arises from the tibial nerve. From the saphenous nerve, impulses go to the middle part of the ankle and the medial part of the tarsus. In some people, this nerve is longer and ends right at the base of the first finger.

The medial cutaneous dorsal nerve passes along the middle area of the foot and is divided along its length into branches that go to the skin of the dorsum of the big toe and partially to the second and third toes.

The intermediate cutaneous dorsal nerve is divided into digital branches, which extend to the areas of the third and fourth, as well as the fourth and fifth toes facing each other.

The lateral dorsal cutaneous nerve carries impulses to the lateral surface of the fifth digit.

A feature of the innervation of the human foot, namely its rear, is its significant variability. For example, some people lack the dorsal cutaneous nerve.

Nerves of the sole of the foot

Innervation of the foot muscles of the plantar part is provided by the plantar nerves: medial and lateral. Both of these nerve trunks arise from the tibial nerve.

The medial nerve runs along the median plantar canal and forms a small arch. The beginning of this arch corresponds to the base of the first metatarsal bone, and its end corresponds to the middle of the fourth metatarsal bone. Along the median nerve, the medial calcaneal branches depart from it. They ensure the transmission of nerve impulses to the midplantar part of the heel.

The medial nerve carries impulses to the muscle that abducts the pollicis and also to the flexor digitorum brevis muscle. It's interesting that children younger age Several branches go to the superficial flexor at once. Then branches emerge from the medial plantar nerve, which innervate the facing surfaces of the first to fourth fingers. These branches are called the first, second and third common digital plantar nerves. The innervation of the toes of the sole of the foot is carried out to a greater extent by these branches.

The lateral nerve is located between the quadratus muscle and the flexor digitorum brevis muscle. It also has two branches: superficial and deep. They arise from the nerve at the base of the metatarsal bone. The superficial nerve gives off several branches: the digital nerve of the lateral edge of the fifth finger, the common digital nerve. They innervate the skin on the surfaces of the fourth and fifth fingers facing each other.

What is neuropathy?

Neuropathy of the lower extremities is not a diagnosis, but a collective concept for diseases in which the peripheral nervous system. First of all, the distal parts of the extremities are affected - the innervation of the lower leg and foot.

There are indeed many reasons for this problem, and clinical symptoms are also variable. Neuropathies are manifested by disorders of movement, sensitive areas, trophism of the skin and muscles.

It is possible to develop mononeuropathy (damage to one nerve) or polyneuropathy (multiple damage to several nerve fibers at once).

Causes of neuropathy

There can be many reasons that lead to disruption of the innervation of the foot. The main ones are listed below:

alcohol abuse;
drug use;
prolonged exposure to toxic substances, especially salts of heavy metals: lead, mercury, arsenic;
endocrinological diseases: diabetes mellitus, thyroid pathologies;
severe liver disease;
prolonged deficiency of vitamins and nutrients;
side effect some medicines: "Amiodarone", "Isoniazid", cytostatics;
severe infectious diseases: diphtheria, HIV infection, mumps;
autoimmune diseases in which antibodies are produced against the body’s own cells: systemic lupus erythematosus, dermatomyositis, rheumatoid arthritis;
genetic predisposition.

Symptoms of neuropathy

Clinical manifestations of neuropathy depend on which nerve function is impaired: sensory, motor or trophic (nutritive). It is noteworthy that the most distal sections are the first to suffer. Therefore, the innervation of the toes will suffer first. As the disease progresses further, the symptoms will spread higher.

Sensitive disorders manifest themselves as follows:

Painful sensations of a pulling or aching nature that correspond to the zone of innervation of the affected nerve.
So-called paresthesia - a sensation of goosebumps crawling on the skin, tightening, twisting of the foot. Sometimes these sensations are so unpleasant that patients would prefer leg pain to them.
Impaired sensitivity. Moreover, there is a simultaneous loss of all types of sensitivity in the zone of innervation of the affected nerve: pain, temperature, tactile.
Sometimes sensory ataxia develops. This is a condition in which a person experiences unsteadiness when walking due to the fact that they cannot feel the position of their feet. This occurs due to a violation of the deep sense of orientation of body parts in space.

The following manifestations are characteristic of movement disorders:

tremor and spasms in muscles whose innervation is impaired;
with a long-term process, muscle weakness develops;
flaccid paralysis- the patient loses the ability to move the foot;
decreased reflexes, which are detected during a neurological examination.

Due to impaired innervation of muscles, foot deformation develops due to muscle atrophy. Atrophy occurs both due to inactivity of the muscle during paralysis, and due to damage to the trophic function of the corresponding nerve.

Consequences of innervation disturbance

Long-term disruption of the innervation of the toes and other parts of the lower extremities can lead to irreversible consequences. Restoring nerve function is a rather complex and not always feasible process, especially if treatment is untimely and incorrect.

Atrophic changes in the foot area first lead to dry skin. Then ulcers and cracks appear, which are very difficult to heal. If you do not follow the rules of personal hygiene, an infection can get there.

With prolonged inactivity of the foot, restoration of its function is difficult. Thus, paralysis of the lower extremities may remain for the rest of life. Therefore, when treating neuropathy, attention is paid not only to drug treatment methods, but also to physical therapy.

Pain and unpleasant paresthesias can lead to psychological problems at the patient. Therefore, sometimes there is a need to take antidepressants.

Conclusion

The feet are a truly important part of the human body. Therefore, not only a medical worker, but also the average person should know general principles anatomy of the foot, features of its blood supply and innervation. It is also necessary to have an understanding of what neuropathy is and how it manifests itself in order to seek medical help in time.

FOOT SURGERY

Second edition, revised and expanded

CHERKES-ZADE

Dursun Ismailovich - Doctor of Medical Sciences, Professor, Honored Scientist of the Russian Federation, Academician of the Academy of Medical and Technical Sciences. 42 years of his life are inextricably linked with the Central Institute of Traumatology and Orthopedics named after. N.N. Priorova. Surgeon high class, D.I. Cherkes-Zadeh performs complex operations on large joints, pelvic bones and feet, widely using the Ilizarov method. Author of 255 scientific and methodological works, including 5 monographs. Under his leadership, 31 dissertations were prepared and defended.

Yuriy Fedorovich - trauma surgeon, Doctor of Medical Sciences, Professor. Born in 1947. From 1984 to 2000 he worked at the Central Institute of Traumatology and Orthopedics named after. N.N. Priorova. Author 152 scientific works. Under his leadership, 11 dissertations were defended. Currently lives in Argentina.

PREFACE

Cherkes-Zade D.I., Kamenev Yu.F.

The second edition of the monograph (the first was published in 1995) summarizes the authors’ own experience and literature data on the diagnosis and treatment of the most serious and common foot injuries and diseases in clinical practice. In the general part, the anatomical, physiological and biomechanical features of the foot are considered, the methodology for examining patients is described, and the principles for diagnosing injuries and diseases of this organ are outlined. A special part discusses specific treatment issues. various types foot injuries and new directions in the development of this problem. Much attention is paid to foot diseases. The second edition of the book contains new data on the diagnosis and treatment of injuries and diseases of the foot.

For surgeons and traumatologists.

Cherkes-Zade D.I., Kamenev Yu.F.

Surgery on the Foot. Second ed., revised and supplemented, 2002/

The second version of this monograph (the first was issued in 1995) sums up the authors' experience and published data on the diagnosis and treatment of the most serious and incident injuries and diseases of soles. The general part presents the anatomy, physiology, and biomechanical of the soles, describes methods of examination and diagnosis of injuries and diseases. The specific part discusses problems in the treatment of various injuries of soles and new trends in the treatment. Special attention is paid to diseases of the soles. The second version of the book contains new data on the diagnosis and treatment of injuries and diseases of the soles.

Addressed to surgeons and traumatologists.

In 1995, the book “Foot Surgery” by Professor D.I. Cherkes-Zade and Yu.F. Kamenev was published.

Over the past years, life has made adjustments to some methods of diagnosing and treating injuries and diseases of the foot, so there was a need to republish the monograph.

The second, revised and expanded edition of D.I. Cherkes-Zade and Yu.F. Kamenev “Foot Surgery” in comparison with the old editions of the 50-60s [Bogdanov F.R., 1953; Yaralov-Yaralyants V.A., 1969], published in small editions, are essentially a short manual that could not meet the increased needs of orthopedic traumatologists. In this regard, this book fills a gap in this area of knowledge.

At the Central Research Institute of Traumatology and Orthopedics named after. N.N. Priorov has accumulated extensive experience among the staff of many departments in the treatment of injuries and diseases of the foot, which is especially important for practical healthcare.

The relevance should be emphasized brief description anatomical and physiological characteristics of the foot and its biomechanics, as well as clinical and x-ray examination.

A special part is devoted to traumatic injuries and chronic fracture-dislocations, gunshot wounds, static deformities, congenital pathology, as well as various diseases feet, including tumor lesions.

The clinical experience of the authors of this book in the use of external transosseous fixation devices in the treatment of both closed and open fractures and fracture dislocations of the forefoot, middle and hindfoot is invaluable. Considerable attention is paid to the tactics of treating open and gunshot injuries of the foot, as well as purulent
wound infection, which is one of the most serious complications in the destruction of soft tissues.

It is quite logical to cover the problems of degenerative-dystrophic diseases of the foot, ischemic lesions, osteochondropathy, and paralytic deformities.

Congenital foot deformities and neurotrophic syndromes are highlighted in separate chapters. Information about the most common foot tumors is also helpful.

The publication of the book “Foot Surgery” by D.I. Cherkes-Zade, Yu.F. Kamenev seems extremely timely and useful, especially considering that medical care for patients with foot pathology has to be provided, along with traumatologists, to doctors of other specialties, and will also be very necessary for researchers, teachers of departments of traumatology and orthopedics.

Academician of the Russian Academy of Medical Sciences Professor S.P. Mironov

^ GENERAL PART

Chapter 1

ANATOMICAL, PHYSIOLOGICAL AND BIOMECHANICAL FEATURES OF THE FOOT

1.1. Osteoarticular apparatus of the foot

In manuals on human anatomy, the foot is divided into the tarsus, metatarsus, and phalanges. In clinical practice, it is also customary to divide it into three sections - anterior, middle and posterior. The forefoot includes the phalanges of the toes and metatarsals, the middle section includes the sphenoid, navicular and cuboid bones, and the posterior section includes the talus and calcaneus. The skeleton of the foot, in addition to these bones, includes the distal ends of the bones of the lower leg. The bones of the lower leg, like a fork, cover the block of the talus and together with it form the ankle joint.

In the talus there is a body (posterior section) that passes into the posterior process; the last groove is divided into two tubercles. There are three most common shapes of the posterior edge of the talus: dentate, hamate and oval. Damage to the posterior process is most often observed in the first of these forms, less often in the second, and almost never occurs in the third. When the posterior process is strongly pronounced, its outer part is a separate triangular (additional) bone; it must be differentiated from a fracture of the posterior edge of the talus. The presence of a fracture is often indicated by the mechanism of injury, as well as jagged (uneven) contours, clearly visible on low-hardness radiographs [ReutN. E., 1975].

The calcaneus is located inferiorly and posteriorly to the talus. Its extra-articular part - the body of the calcaneus - ends with a formation that looks like a tubercle. The extensive posterior talar articular surface of the calcaneus (subtalar joint), and the anterior and middle talar articular surfaces (talocaleonavicular joint) take part in the formation of articulations with the talus bone.

On the outside, the calcaneus articulates with the cuboid; The calcaneocuboid joint is formed by the cuboid articular surface of the calcaneus and the posterior articular surface of the cuboid. In case of compression fractures of the calcaneus, the severity of the injury, the choice of treatment method and the prognosis are determined mainly by the nature of the damage to the subtalar and calcaneocuboid joints, as well as the degree of displacement of bone fragments.

The navicular bone, which is closely connected with other bones of the midfoot, is important in the architecture of the foot. It is located in the area of the inner edge of the foot between the head of the talus and the three wedge-shaped bones. The lateral surface of the scaphoid has a small articular surface for articulation with the cuboid. The lower surface of the scaphoid along the medial edge is somewhat pointed and forms a tuberosity that can be easily palpated through the skin, on the lower surface of which there is a facet for the sesamoid bone. Sometimes the tuberosity is not associated with the scaphoid bone, being an independent bone formation.

On the anterior surface of the scaphoid there are three articular platforms for connection with the sphenoid bones, the size and shape of which are not the same. Due to the fact that the intermediate cuneiform bone is shorter than the others, the base of the second metatarsal bone is located in a niche formed by the lateral surfaces of the medial and lateral cuneiform bones.

The lateral edge of the midfoot is represented by the cuboid bone, located between the calcaneus and the bases and IV-V metatarsal bones. Small area On the inner articular surface, the cuboid bone is in contact with the outer edge of the lateral sphenoid bone and the scaphoid bone. On the lower surface of the cuboid bone in front of the tuberosity there is a groove for the tendon of the peroneus longus muscle, which is a flexor of the foot. This tendon in the area of the plantar surface of the cuboid bone may contain unstable sesamoid bones.

The bones of the midfoot take part in the formation of three functionally important joints, characterized by the complexity of the anatomical relationships of the bone formations. A diagram of the joints and ligaments of the foot is shown in Fig. 1.1.

The articular line of the talocaleonavicular and calcaneocuboid joints looks like an S-shaped curve. These two joints, the cavities of which are separate, represent the transverse tarsal joint (Chopard's joint). Strong fixation of the joint is provided by a bifurcated ligament, originating on the dorsum of the heel bone at its anterior edge. The ligament has two parts: one is attached to the dorsum of the cuboid bone (calcaneocuboid ligament), the other is attached to the navicular bone (calcaneonavicular ligament). The bifurcated ligament is considered the “key” of the Chopart joint, since none of the ligaments located in the circumference of this joint can compare with it in strength.

Anterior to the transverse tarsal joint is the wedge-cuboid-navicular joint, which has a complex structure. It is formed by the articular surfaces of the scaphoid bone and the three wedge-shaped bones (sphenovavicular joint), as well as the articular surfaces of the cuboid, scaphoid and lateral cuneiform bones facing each other, which form a separate joint. The cavities of both joints communicate with each other and are connected to the cavity of the tarsometatarsal joint. The sphenocuboid-scaphoid joint is strengthened by many strong ligaments located between adjacent bones, including in the joint cavity. The joint is a low-moving joint.

The boundary between the forefoot and midfoot is a line passing in the area of the articulation of the tarsal bones with the metatarsal bones - the Lisfranc joint. It is formed in front by the articular surfaces of all metatarsal bones, and behind by the articular surfaces of the cuboid and all sphenoid bones. The component parts of the joint are closely connected to each other by many ligaments, which ensures high strength of the foot under mechanical loads.

The ligamentous apparatus of the Lisfranc joint consists of the dorsal and plantar tarsometatarsal and interosseous sphenometatarsal ligaments connecting the bases of the metatarsal bones

rns. 1.1.-Joints and ligaments of the foot [Movshovich I.A., 1983].

1 - ankle joint; 2, 3 - talocaleonavicular joint (Chopard's joint); 4 - wedge-navicular joint; 5, 7 - tarsometatarsal Lisfranc joint; 6 - interosseous wedge-metatarsal ligament (“key” of the Lisfranc joint); 8 - bifurcated ligament (“key” of the Chopart joint); 9 - interosseous talocalcaneal ligament; Y - posterior talofibular ligament; 11 - tibiofibular syndesmosis.

Rice. 1.2. The “key” of the Lisfranc joint is the ligament between the second metatarsal and medial cuneiform bone.

1 - medial sphenoid bone; 2 - II metatarsal bone; 3 - interosseous wedge-metatarsal ligament; 4 - peroneus longus tendon; 5 - I metatarsal bone.

With sphenoid and cuboid bones. The most powerful of the Lisfranc joint ligaments is the medial interosseous sphenometatarsal, which connects the medial sphenoid bone to the base of the second metatarsal. This ligament is the “key” of the Lisfranc joint (Fig. 1.2): only its damage leads to dislocation of the bases of the metatarsal bones in this joint. Due to the strong connection of the bones fixed by this ligament, a dislocation in the Lisfranc joint is very often combined with a fracture of the base of the second metatarsal bone, sometimes simultaneously with a marginal fracture of the medial sphenoid bone.

The forefoot is composed of five metatarsal bones and phalanges of the toes. The bodies of the metatarsal bones have a triangular shape; in front they end with a hemispherical articular surface - the head, which articulates with the proximal phalanx of the corresponding finger. The most massive are the proximal ends of the metatarsal bones, called the bases. The posterior surface of the bases is represented by articular surfaces intended for articulation with the tarsal bones.

The bases of the metatarsal bones fit tightly to each other and articulate through articular platforms located on the lateral surfaces. The base of the fifth metatarsal bone has a tuberosity on the outer side, which serves as the attachment point for the tendon of the peroneus brevis muscle. Pain in this place may indicate not only a fracture of the base of the fifth metatarsal bone, but also the presence of bursitis, which has developed as a result of pressure on the skin from shoes that do not fit the foot.

On the lower surface of the head of the first metatarsal bone, sesamoid bones are often located on the sides. Pathology of these bones can cause pain. A common location of sesamoid bones on the foot is also the area of the interphalangeal joint of the big toe.

Metatarsal bones have different mechanical strength, which explains the unequal frequency of their fractures. With the help of special studies, it has been established that the mechanical strength of the I and V metatarsal bones is almost 3 times higher than the rest. Different parts of the metatarsal bones also have unequal strength. The compact substance is least pronounced in the area of the heads and bases of the metatarsal bones. It is in these areas that fractures most often occur.

Toes are an important part of the foot. Their bone base is made up of short tubular bones - phalanges, which in shape, number and relationships correspond to the phalanges of the fingers. Fingers II-V have three phalanges (proximal, or main, middle and distal, or nail), I - two (proximal and middle). Each phalanx has a body and two ends: the anterior (distal) - the head and the posterior (proximal) - the base.

The bones of the forefoot take part in the formation of the metatarsophalangeal and interphalangeal joints, which play an important role in the implementation of the supporting and locomotor functions of the foot.

^ 1.2. Muscles, fascia and tissue spaces of the foot

On the dorsum of the foot, the muscles are located in two rows. Directly under the dorsal fascia of the foot are the tendons of the lower leg muscle group: the anterior tibialis muscle (attachment site - the medial wedge-shaped bone and the base of the first metatarsal bone), extensor longus fingers (attachment site - the bases of the middle and distal phalanges of the II-V fingers), long extensor pollicis (attachment site - the bases of both phalanges of the first finger), unstable third peroneal muscle (attachment site - the base of the V metatarsal bone).

Under the tendons of the anterior group of muscles of the leg there are the own muscles of the foot - the short extensor of the II-V fingers and the short extensor of the big toe. The muscles originate on the upper and outer surfaces of the anterior part of the heel bone and are attached to the base of the proximal phalanges of the toes.

On the plantar surface, the muscles are located in four fascial beds, delimited by fibrous septa extending from the plantar aponeurosis. There is a medial bed in which the muscles of the thumb pass; lateral, containing the muscles of the fifth finger; the middle one, containing the tendons of the short flexor muscles of the fingers, the quadratus plantae muscle and the lumbrical muscles, and, finally, the deep median bed, in which the interosseous muscles lie.

In the medial bed, the abductor pollicis muscle is located superficially and medially (the place of attachment is the base of the proximal phalanx of the thumb), the tendon of the flexor pollicis longus passes superficially and laterally (the place of attachment is the base of the distal phalanx of the thumb); in the depths of the bed there are the lateral and medial heads of the flexor pollicis brevis (the attachment site of the tendon of the lateral head of the muscle is the lateral sesamoid bone and the base of the proximal phalanx of the thumb, the tendons of the medial head are the medial sesamoid bone and the base of the proximal phalanx of the thumb) and the adductor pollicis muscle (the place of attachment of the common tendon of the transverse and oblique heads of the muscle is the lateral sesamoid bone and the base of the proximal phalanx of the thumb).

In the lateral bed, the muscle that abducts the little toe passes superficially and most laterally (the place of attachment is the lateral side of the base of the proximal phalanx of the fifth finger), medial to this muscle lies the short flexor of the little toe (the place of attachment is the base of the proximal phalanx of the fifth finger), which covers and merges with muscle opposing the fifth finger (attachment site - the lateral edge of the fifth metatarsal bone).

In the middle bed, the short flexor of the fingers lies superficially, the muscle belly of which passes into four tendon cords extending to the II-V fingers. At the level of the proximal phalanges, each of the tendon cords is divided into two heads, attached to the base of the middle phalanges of the indicated fingers. The tendons of the long flexor of the II-V fingers pass between the heads (the place of attachment is the base of the distal phalanges). Under the short flexor of the II-V fingers is the quadratus plantae muscle (having the shape of a quadrangle). This muscle is attached to the outer edge of the flexor digitorum longus tendon at the site of its division into individual tendons. Between them, in the distal part of the foot, there are thin lumbrical muscles that arise from the corresponding tendon of the long flexor of the II-V fingers. In the area of the metatarsophalangeal joints, the lumbrical muscles bend around the II-V fingers from the medial side and, moving to the dorsal surface of these fingers, are woven into the dorsal fascia of the foot.

In the deep median bed, interosseous muscles are located in two layers. The first layer contains the plantar interosseous muscles, the second layer contains the dorsal interosseous muscles.

The plantar surface is also the attachment point for the lower leg muscles, which lie here outside the fascial muscle beds. These include the rear tibialis muscle(place of attachment - tuberosity of the scaphoid bone, the lower surface of the three wedge-shaped bones and the base of the II-V metatarsal bones); long peroneus muscle(its tendon lies in the groove of the cuboid bone and is attached to the tuberosity of the first metatarsal bone and to the medial sphenoid bone); peroneus brevis muscle (located on the outer surface of the heel bone and attached to the tuberosity of the fifth metatarsal bone); triceps surae muscle [at the site of attachment to the tubercle of the calcaneus it forms a powerful calcaneal (Achilles) tendon].

The muscle mass of the foot is most pronounced on the plantar surface and much less in the rear area. The unity of action of the muscles of the rear and plantar surface ensures normal motor function of the foot and toes.

Fascial formations and cellular spaces of the foot are of great importance, which is determined primarily by the possibility of accumulation of blood and purulent contents in these places and, in connection with this, the risk of developing various kinds of complications: hypertensive ischemic syndrome due to the intractable fascia delimiting the cellular spaces; spread of purulent contents along the interconnected spaces of the foot and lower leg; intoxication with decay products of soft tissues, etc. It is clear that in these and a number of other cases, the success of treating patients will largely depend on how well the surgeon understands the topography of the fascia and cellular spaces of the foot.

On the dorsum of the foot, two cellular spaces are distinguished: subcutaneous and subfascial. The border between them is the dorsal fascia of the foot, which lines the subcutaneous fatty tissue from the depths. The latter is poorly developed and has a lamellar character. The branches of the superficial peroneal and cutaneous nerves and the venous network of the dorsum of the foot pass through its thickness.

In the subfascial tissue space there is a dorsal fascial bed for the extensor muscles of the dorsum of the foot. This bed is formed by a split in the dorsal fascia of the foot. The latter is also involved in the formation of muscular and neurovascular sheaths and fibrous canals of the dorsum of the foot. In the dorsal fascial bed, the following formations pass sequentially from inside to outside: the canal of the tendon of the anterior tibialis muscle (medial fibrous canal), the canal of the long extensor pollicis (middle fibrous canal), the canal of the long extensor digitorum (lateral fibrous canal). Under the middle fibrous canal there is a vascular canal, where the dorsal artery of the foot passes, giving off a branch at the level of the bases of the metatarsal bones - the arcuate artery. From it to the interdigital spaces go thin metatarsal arteries, which in turn are divided into dorsal digital arteries. The dorsal artery of the foot is accompanied along its entire length by two veins of the same name and branches of the deep peroneal nerve. The tendons are located even deeper short extensors fingers.

The dorsal fascial bed, being a continuation of the anterior fascial bed of the leg, communicates with it through fibrous canals where the synovial sheaths of the extensor tendons pass. The cellular spaces of the dorsum of the foot are delimited from the fascial beds of the sole by the dorsal interosseous fascia. The latter, in the first intermetatarsal space, contains a cellular fissure into which the deep plantar branch of the dorsal artery penetrates, participating in the formation of the plantar arch. From here, leakage into the middle fascial bed of the sole is possible.

The sole area is of surgical importance. The topographic-anatomical connections of the cellular spaces located in this area must be known, first of all, for the correct diagnosis of inflammatory processes and identification of the ways of spread of purulent leaks. In this regard, attention should be paid to following points: 1) the possibility of necrosis of the skin of the sole during its traumatic detachment due to the separation of blood vessels vertically approaching the skin; 2) the absence of pronounced clinical manifestations in deep purulent accumulations under the aponeurosis.

The middle fascial bed of the sole plays a major role in the spread of purulent diseases of the foot. It has two cellular spaces: superficial, in which the flexor digitorum brevis is located, and deep, containing the flexor digitorum longus tendon with the quadratus and lumbrical muscles. The boundary between these cellular spaces is the fascia covering the tendons of the long flexor digitorum and the quadratus plantaris muscle. In depth, the middle fascial bed of the foot is limited by the plantar interosseous fascia, covering the metatarsal bones and interosseous muscles, and on the surface by the plantar aponeurosis.
The connection of the middle fascial bed of the sole with other cellular spaces of the foot and lower leg is carried out along the fiber surrounding the neurovascular formations, along the tendons of the muscles and their sheaths, as well as through weak spots in the fascia delimiting the cellular spaces.

The connection between the cellular spaces of the middle fascial bed of the sole and the dorsum of the foot can be carried out in two ways: 1) along the lumbrical muscles and the thin fascial sheaths surrounding them; 2) along the fiber surrounding the deep plantar branch of the dorsal artery, passing in the first intermetatarsal space.

The cellular spaces of the middle fascial bed and subcutaneous fatty tissue communicate with each other along the intermetatarsal vascular branches, anastomosing through the commissural openings with the plantar digital vessels. These connections between the middle fascial bed of the sole and the subcutaneous fatty tissue of the foot and toes determine the transition and spread of the inflammatory process from the subcutaneous fatty tissue both in depth and back. One must always take into account the possibility of generalization of infection and the development of phlegmon of the foot when treating superficial inflammatory diseases of the foot and fingers.

The topographic-anatomical connections of the middle fascial bed of the sole with the cellular spaces of the posterior surface of the lower leg are of great practical importance. The poorly strengthened posterior wall of the bursa may play a role in the spread of the inflammatory process. ankle joint, to which the fiber surrounding the tendon of the long flexor pollicis is adjacent. The fiber of this and a number of other muscles (tibialis anterior, flexor digitorum longus tendon), as well as neurovascular formations located in the heel canal, is a means of connecting the deep cellular space of the middle fascial bed of the sole with the deep fascial bed of the lower leg. The latter is also associated with the anterior fascial bed of the leg.

The lateral and medial fascial beds of the sole are of particular importance in the development and spread of inflammatory processes on the foot.

In the lateral fascial bed there are muscles of the fifth finger enclosed in fascial sheaths. They are delimited from the muscles of the middle fascial bed by a fibrous septum, which is projected onto a line running from the middle of the transverse line of the sole to the third interdigital space. The lateral fascial bed has the largest area in the proximal part of the sole, where it corresponds to approximately 2/3 of the plantar aponeurosis. The connection of the lateral fascial bed of the sole with the middle one is carried out along the tendon of the short flexor of the little toe, which passes through the external fibrous septum. This connection can also occur along the fiber surrounding the quadratus muscle during its transition from the middle fascial bed of the plantar to the lateral bed. No less important in the spread of the purulent process is the deep cellular fissure of the tarsus, located between the muscle that abducts the little toe and the heel bone.

The medial fascial bed of the sole is separated from the middle by a fibrous septum, which is projected onto a line drawn from the middle of the inner half of the width of the sole to the first interdigital space. The connection between the medial fascial bed of the sole and the middle one is carried out along the tendon of the long flexor pollicis, which passes through the internal fibrous septum.

^ 1.3. Blood supply to the foot and lymphatic drainage

The blood supply to the foot is provided by the dorsalis pedis artery, which is a continuation of the anterior tibial artery, as well as the medial and lateral plantar arteries - the terminal branches of the posterior tibial artery. The projection of the dorsal artery of the foot is a line drawn from the middle of the distance between the ankles to the first intermetatarsal space. With insufficiently developed plantar arteries, the dorsalis pedis artery supplies the plantar surface through perforating branches that connect the dorsalis pedis artery to the plantar arch. Sometimes the dorsal artery of the foot is poorly developed; in these cases, the dorsum of the foot is supplied with blood through piercing branches from the well-developed plantar arch.

According to A.P. Pospelova (1960), the dorsal artery of the foot in 10.3% of cases arises from the perforating branch of the peroneal artery, in 14.5% of cases it is located 1-2 cm inward or outward from the projection line, in 2.3% of cases % of cases have a small diameter and branch at the base of the first metatarsal bone, giving off 2-3 lateral branches along the way. The dorsum of the foot is supplied with blood from the plantar arch through the perforating branches. Consequently, the absence of pulsation of the dorsal artery of the foot on the projection line is not a mandatory sign of its closure.

The author draws attention to the fact that the dorsal artery of the foot can be located superficially, i.e. come out under the skin. With this arrangement, the dorsal artery of the foot can be easily vulnerable. And if we consider that it is often the main arterial bed in the foot and supplies blood not only to the rear of the foot, but also strengthens the plantar arch through the deep plantar branch, then a violation of the integrity of the artery will, to one degree or another, affect the blood supply to the entire foot.

The venous network of the foot is well defined; there are superficial and deep venous networks. In the area of the base of the fingers there is a plantar venous arch, which receives blood from the plantar veins of the fingers and anastomoses with the dorsal venous arch through the interosseous spaces. The outflow of blood from the plantar venous arch is carried out into the system of the posterior tibial veins.

The outflow of blood from the bones of the foot occurs through the intraosseous veins or through the veins of the periosteum and then through the great saphenous vein of the leg, the anterior tibial vein, the small saphenous vein of the leg and the posterior tibial veins. There is a very dense network of anastomoses between the veins.

The outflow of lymph from the anterior surface of the foot and ankle occurs through lymphatic vessels running parallel to the anterior tibial artery. From the inside of the foot and ankle, lymph drains through vessels parallel to the posterior tibial artery; from the outside of the foot and ankle, through vessels running parallel to the peroneal artery.

The diagram clearly shows the complexity of the cause-and-effect relationships between various factors influencing the state of peripheral hemodynamics in this pathology. When the foot and ankle joint are damaged, the relationship between disorders of regional hemodynamics in the lower leg, tissue blood flow in the muscles and ligaments of the foot and microcirculation of its skin is revealed from the very beginning in the form of a vascular reaction of the injured limb. Research results confirm that the main hemodynamic disorders in the foot and leg are associated with a decrease in circulating blood volume. According to RVG and USDG, vasomotor disorders in such patients are manifested by an increase in the tone of large arteries, medium- and small-caliber vessels, and impaired blood flow and outflow into them. Moreover, changes in the general peripheral resistance of the vascular bed of the leg and foot are synchronous and manifest themselves as vascular reflex reactions in response to irritation of the nervous elements of the tissues of the injured organ. Peripheral hemodynamic disturbances in both the lower leg and foot are caused primarily by spasm of the main arteries. However, one cannot ignore other factors that influence the state of blood circulation in the injured limb. This may be compression of the vessels of the foot by edematous tissue or hematoma, damaged bones, complete or partial disruption of their integrity, thrombosis of the veins of the limb. The resulting circulatory disorders lead to ischemia of the tissues of the foot and ankle joint, which in the absence of adequate treatment leads in turn to the development of necrosis.

The state of regional blood circulation in the foot area is significantly influenced by the mechanism of injury. With a direct mechanism of injury, disturbances in peripheral hemodynamics caused by prolonged arterial spasm are aggravated mainly by damage to medium-sized vessels, which is confirmed by the comparative dynamics of rheograms after taking nitroglycerin. In contrast to indirect foot injury, in which spasm of the main arteries plays a leading role in changing the nature of the rheographic curve, and vascular injuries are limited to capillaries, small arteries and veins, and therefore the reaction vascular system to taking nitroglycerin is quite long-lasting (1 - 1.5 hours), in victims with a direct mechanism of organ injury, this reaction is short-lived (16-18 minutes) and less pronounced, which gives grounds to attribute it to injuries to vessels of a larger caliber. In this case, even relieving vascular spasm does not help to significantly increase arterial inflow, especially for a long time. It is obvious that this circumstance must be taken into account when choosing a method of treating patients.

When studying the distribution of circulating blood in the foot area, a peculiar redistribution is revealed between the capillary bed of the skin and the vascular bed of the underlying tissues (muscles, ligaments, fascia). The correlation relationships between these vascular pools have their own characteristics, namely, a clear inverse relationship: the worse the tissue blood flow of the muscles and ligaments of the foot, the more pronounced the hyperthermia of the skin, caused by the increased flow of blood into the capillary network of the latter. The phenomenon of reactive hyperemia of the skin during ischemia of the tissues of the foot, apparently, can be considered as a compensatory reaction, indicating the discharge of blood from the spasmodic arterial bed into the dilated capillaries of the skin, carried out due to the opening of arteriole-venous anastomoses. Undoubtedly, the redistribution of blood flow in the injured foot is based on multidirectional changes in the tone of resistive co-vascular vessels of the skin, on the one hand, and the underlying tissues (muscles, ligaments) on the other. The presence of such a dependence in the development of peripheral hemodynamic disorders in the foot area
makes it clear to detect foci of necrosis of muscles and ligaments under visually intact skin and makes it possible to assess the state of blood flow of the underlying tissues, focusing exclusively on thermographic or thermometric indicators, depending on the equipment of the medical institution necessary for carrying out these studies. Judging the essence of circulation disorders based on indirect data facilitates the diagnosis of ischemic conditions of the tissues of the injured foot, since in these cases there is no need to use more complex research methods and expensive equipment, which is not available in all medical institutions.

^ 1.4. Innervation of the foot

The foot is innervated by the longest branches of the lumbar and sacral plexus. The innervation of the dorsum of the foot involves the saphenous nerve, which innervates the medial edge of the foot; lateral dorsal cutaneous nerve, branches of the superficial peroneal nerve - medial and intermediate dorsal cutaneous nerves, as well as the terminal branch of the deep peroneal nerve. On the plantar side of the foot, the skin and muscles are innervated by the medial and lateral plantar nerves, which are the terminal branches of the tibial nerve. When the bones of the foot are fractured, branches from these nerves are often involved in scar tissue, which causes pain when walking, especially with improperly healed fractures.

^ 1.5. Function and biomechanics of the foot

Normally, the foot has three main functions: springing, balancing and pushing. The spring function is the ability of the foot to elastically flatten under the influence of sharply changing vertical loads. The balancing function is manifested in the regulation of postural activity when standing and walking. It is ensured by dosed lateral mobility of the foot. The propulsion function is the ability of the foot to impart acceleration to the general center of body mass during locomotion. The pushing function is manifested in the implementation of rear and front pushes.

With different types of movement, accompanied by acceleration, braking or turning, displacement forces arise, which are withstood by the skin, subcutaneous fatty tissue, and connective tissue partitions. In the area of the heel and metatarsophalangeal joints, the orientation of the collagen strands is in strict accordance with the direction of the forces acting on the foot. The skin in these places is characterized by significant density, increased dynamic viscosity, proximity to the underlying bones and their mutual fixation.

The skin of the foot is abundantly supplied with pain receptors, and their number on the plantar surface is the same as on the palms of the hands. When a person stands and walks through his foot, he interacts with external environment, and information from proprioceptors located in the foot is the most subtle and differentiated. The arched structure of the foot creates the precondition that changes in load cause disturbance in a large number of joints of the foot. In total, there are 20 joints in the foot, which have 24 degrees of mobility. During walking, the foot is able to actively “track” the unevenness of the relief of the supporting surface to maintain the constancy of the support reactions. These response processes have a high speed and are provided through afferent-efferent nerve connections due to the active functions of the muscles of the lower leg and foot.

Constant contact of one or two feet with the supporting surface is a characteristic feature of walking. Walking is characterized by an alternation of two periods: 1) the period of support, during which the foot comes into contact with the support, and 2) the period of transfer, when the free leg is carried forward, i.e. takes another step. During the period of support, a roll of the foot occurs, during which the process of pushing off the support and moving the body forward is observed. The foot interacts with the support in three directions: vertical, longitudinal and transverse. The vertical component accounts for 90% of the value ground reaction.

The foot is divided into longitudinal and transverse arches. The longitudinal arch is divided into internal and external parts (internal and external arches). Interior The longitudinal arch is formed by the talus, navicular, three sphenoid bones and three metatarsal bones. This part of the arch is higher than the outer one. The outer part of the longitudinal arch of the foot is formed by the calcaneus, cuboid and two metatarsal bones - IV and V. The inner part of the arch of the foot mainly performs a spring function, and the outer part - a supporting one.

Until recently, the presence of an anterior transverse arch was recognized based on indirect signs. Currently, there is a known method of direct x-ray 108" of the anterior transverse arch of the foot [Mitelman N.Yu., ub8], which objectively confirms its presence on all feet.

PELVIC AREA

M.iliopsoas supply blood a.iliolumbalis et a.circumflexa ilium profunda (branches a.iliac interna ).

M.obturatorius internus, mm.gemelli superior et inferior – a.glutea inferior, a.obturatoria, a.pudenda interna(branches a.iliac interna ).

M.piriformis– aa.gluteae superior et inferior (branches a.iliac interna ).

M. gluteus maximus supply blood aa.gluteae superior et interior (branches a.iliac interna ) And (branch a.profunda femoris ).

Mm. glutei medius et minimus,m.tensor fasciae latae– a.glutea superior (branch a.iliac interna ) And a.circumflexa femoris lateralis (branch a.profunda femoris ).

M.quadratus femoris– a.glutea inferior,a.circumflexa femoris medialis,a.obturatoria.

M.obturatorius externus– a.obturatoria, a.circumflexa femoris medialis.

Venous blood flows through the parietal branches v. iliaca interna (internal iliac vein).

In Group internal muscles pelvis:

M.iliopsoas(iliopsoas muscle) is innervated by the muscular branches of the lumbar plexus.

M.obturatorius internus(internal obturator muscle), mm.gemeli superior et inferior (superior and inferior gemellus muscles), m.piriformis (piriformis muscle) are innervated by the muscular branches of the sacral plexus.

Among outdoor groups pelvic muscles:

M. gluteus maximus innervated n.gluteus inferior (inferior gluteal nerve from the sacral plexus).

M. gluteus medius And m.gluteus minimus (gluteus medius and minimus), m.tensor fascia lata (tensor fascia lata) are innervated n.gluteus superior (superior gluteal nerve from the sacral plexus).

M.quadratus femoris(quadratus femoris muscle) innervated n.ischiadicus (sciatic nerve from the sacral plexus).

M.obturatorius externus– n.obturatorius (obturator nerve from the lumbar plexus).

Leather above gluteal muscles innervated nn.clunii superioris ,media And inferioris (superior, middle and lower nerves of the buttocks, formed by the posterior branches of the lumbar and sacral spinal nerves).

HIP

The thigh receives arterial blood mainly from a.profunda femoris (branch a.femoral ), from its branches: aa.circumflexae femoris medialis etlateralis ,aa.perforantes prima, second, tertia.

Blood flows through the veins of the same name, with small-caliber arteries often accompanied by two veins, and large-caliber arteries by one vein.

The thigh muscles are innervated:

Front group – n.femoral (femoral nerve of the lumbar plexus).

Medial group – n.obturatorius (lumbar plexus).

Rear group - n.ischiadicus (sacral plexus).

Leather the thigh is innervated by:

1. Anterior surface immediately below the inguinal ligament - n.genitofemoralis (pudofemoral nerve from the lumbar plexus). The rest of the anterior thigh is innervated rami cutanei anteriores (anterior cutaneous branches n.femoral ).

2. Medial surface – n.obturatorius , lateral surface – n.cutaneus femoris lateralis(lateral cutaneous nerve of the thigh is an independent nerve of the lumbar plexus).

3. Rear surface – n.cutaneus femoris posterior (posterior cutaneous nerve of the thigh from n.ischiadicus ).

SHIN

The leg muscles are supplied with blood from the branches a.poplitea , which is divided into aa.tibialis anterior et posterior.

A. tibialis anterior runs along the front surface of the lower leg and divides into aa .recurrens tibialis anterior et posterior, aa.malleolares medialis et lateralis and passes into the dorsal artery of the foot a.dorsalis pedis.

A.tibialis posterior located in canalis cruropopliteus and gives a.peronea (fibularis), rami malleolares medialis, calcanei and goes into aa.plantares medialis et lateralis. On the plantar surface of the foot a.plantaris lateralis anastomoses with ramus plantaris profundus from a.dorsalis pedis and forms arcus plantaris.

Venous blood flows through the system of deep veins, which accompany double the arteries of the same name, and through the superficial veins:

1. v. saphena magna (lies on the anteromedial surface of the leg and thigh) and flows into v.femoralis;

2. v. saphena parva collects blood from the posterolateral surface of the leg and flows into v.poplitea.

Calf muscles receive innervation from several nerves:

1. Front group – n.peroneus (fibularis) profundus (deep peroneal nerve from n.fibularis communis, branches n.ischiadicus ).

2. Back group – n.tibialis (tibial nerve from n.ischiadicus ).

3. Lateral group – n.peroneus superficialis (superficial peroneal nerve from n.peroneus communis ).

Shin skin innervated:

1. Anteromedial surface – n.saphenus (saphenous nerve from n.femoral ).

2. Lateral surface – n.cutaneus surae lateralis (lateral cutaneous nerve of the leg from n.fibularis communis ).

3. Rear surface – rr.cutaneus surae mediales (medial cutaneous nerve of the leg) - branch n.femoral .

FOOT

Dorsum of the foot supplied with blood from a.dorsalis pedis (continuation a.tibialis anterior , which gives on the foot aa.tarsales mediales et laterales, a. arcuata, a.plantaris profunda ); a.tarsalis lateralis anastomoses with a.arcuata, forming arcus dorsalis pedis , from which they depart aa.tarsales dorsales , divisible by aa.digitales dorsales .

Plantar surface of the foot supplied with blood from the branches aa.plantaris medialis et lateralis ( from a.tibialis posterior); a.dorsalis pedis anastomoses through a. plantaris profundus With a.plantaris lateralis , forming an arc - arcus plantaris profundus . They depart from the latter aa.digitales plantares communes , divisible by aa.digitales plantares propriae .

The outflow paths of venous blood are accompanied by arteries of the same name (small and medium-sized arteries are accompanied by two veins of the same name, large arteries by one vein). The tributaries of the veins correspond to the branches of the arteries, the companions of which are these veins. For example: the popliteal vein is formed by the fusion vv.tibiales anteriores et posteriores .

Muscles the dorsum of the foot is innervated n.fibularis profundus.

On the plantar surface:

1. m.abductor hallucis (abductor pollicis muscle) m.flexor digitorum brevis (flexor digitorum brevis) mm.lumbricales I, II – innervates n.plantaris medialis (medial plantar nerve from n.tibialis ),

2. the remaining muscles of the foot are innervated n.plantaris lateralis (lateral plantar nerve from n.tibialis ).

Foot skin innervated:

1. Along the lateral edge – n.suralis (sural nerve, formed as a result of the fusion rr.cutanei cruris mediales And cutanei cruris laterales ).

2. Along the medial edge – n.saphenus.

3. Skin of the first interdigital space of the dorsum of the foot - n.fibularis profundus.

4. The rest of the skin on the dorsum of the foot - n.fibularis superficialis .

5. Skin of the plantar surface of the medial 3.5 fingers – n.plantaris medialis , remaining 1.5 fingers – n.plantaris lateralis .

Rice. 3. Innervation of the skin of the lower limb

1. R. cutaneus lateralis (n. iliohypogastricus) 2. R. femoralis (n. genitofemoralis) 3. N. ilioinquinalis 4. Nn. clunium superiors 5. R. cutaneus (n. obturatorius) 6. N. cutaneus femoris lateralis 7a. Rr. cutanei anteriores (n. femoralis) 7b. Rr. cutanei cruris medialis (n. femoralis) 8. Nn. clunium medii (posterior branches nn. sacrales)

9a. Nn. clunium inferiors (n. cutaneus femoris posterior) 9b. N. cutaneus femoris posterior 10. N. cutaneus surae medialis (n. tibialis) 11. N. cutaneus surae lateralis (n. tibialis) 12. N. suralis 13. N. cutaneus dorsalis medialis et intermedius (n. peroneus superficialis) 14. N. peroneus profundus 15. N. plantaris lateralis (n. tibialis) 16. N. plantaris medialis (n. tibialis)

CHANNELS, FROWS OF THE LOWER LIMB AND THEIR CONTENTS

On the lower limb, as on the upper, muscles limit various types of spaces in which blood vessels and nerves pass.

In the pelvic area:

ü M.piriformis , passing through foramen ischiadicum majus does not complete it entirely, as a result of which gaps remain:

1. Above the muscle - foramen suprapiriforme. They pass through it n.gluteus superior, a.glutea superior, vv.gluteae superiores ).

2. Below the muscle - foramen infrapiriforme. They pass through it n.gluteus inferior, a. et vv.gluteae inferiores, n.cutaneus femoris posterior, n.ischiadicus, n.pudendus, a. et vv. pudendae internae ). N .pudendus, a. et vv.pudendae internae through foramen ischiadicum minus enter fossa ischiorectalis .

ü Canalis obturatorius . The inner channel opening is limited sulcus obturatorius and top edge m.obturatorius internus . The channel hosts: n.obturatorius (from the lumbar plexus), a.obturatoria (branch a.iliac interna) And v.obturatoria flows into v.iliac interna.

On the hip:

ü Lacuna musculorum limited: laterally and posteriorly - by the ilium, medially - lig.iliopectineum , front – lig.inquinale . Through this hole pass: m.iliopsoas, n.femoralis.

ü Lacuna vasorum limited: front and top – lig.inquinale , behind - lig.pectineale , laterally – arcus iliopectineus , medially – lig.lacunare . Through this hole they come out a.femoralis, v.femoralis . The vein lies medial to the artery. A gap remains medial to the vein, filled with fiber and lymph nodes. Under pathological conditions, a femoral hernia can form here.

ü From the lacunae, the vessels enter sulcus iliopectineus, which is limited on the medial side m.pectineus , from the lateral – m.iliopsoas .

ü This furrow continues into sulcus femoralis anterior , formed on the medial side mm.adductor longus et magnus , from the lateral – m.vastus medialis . In this furrow lie: a.femoralis, v.femoralis, n.saphenus .

ü The anterior groove continues into canalis adductorius , which is limited m.adductor magnus, m.vastus medialis and stretched between them lamina vastoadductoria . The canal has two outlet openings: the front one, in the form of a small slit in the lower section lamina vastoadductoria , they exit through it a., vv.genus descendens, n.saphenus and lower - located in the distal part of the tendon m. adductor magnus at attaching it to femur. The femoral artery passes through this opening into the popliteal fossa, accompanied by the vein of the same name.

In the knee area:

ü Fossa poplitea , popliteal fossa is limited superiorly: laterally m.biceps femoris , medially mm.semimembranosus, semitendinosus , below - heads m.gastrocnemius . The bottom of the fossa is formed by a capsule knee joint, the hole is closed at the back fascia poplitea . In the popliteal fossa, from back to front are located n.tibialis, v.poplitea, a.poplitea (Neva) . From the popliteal fossa, vessels and nerves enter the canalis cruropopliteus.

On the shin:

ü Сanalis cruropopliteus located on the back of the lower leg between m.soleus behind and m. tibialis posterior front. Pass in the channel n. tibialis, a. et vv.tibiales posteriores.

ü Canalis musculofibularis inferior runs parallel to the ankle-popliteal canal, limited fibula And mm.flexor hallucis longus et tibialis posterior . Passes through the channel a.fibularis accompanied by two veins.

On the sole are located:

ü Sulcus plantaris medialis limited m.flexor digitorum brevis And m.adductor hallucis . The furrow contains: a.plantaris medialis (branch a.tibialis posterior ), two companion veins of the same name, n.plantaris medialis (branch n.tibialis ).

ü Sulcus plantaris lateralis - between m.flexor digitorum brevis And m.adductor digiti minimi . The furrow contains: a.plantaris lateralis (branch a.tibialis posterior ), two satellite veins, n.plantaris lateralis (branch n.tibialis ).