How To Tell If You Are Lost

Unlock Your Hip Flexors

Unlock Your Hip Flexors

Get Instant Access

It is difficult to get lost in a lateral direction because you will simply run into the subcutaneous tissue lateral to the tensor fascia. It is quite possible, however, to get lost medially and put the femoral nerve at great risk. The key is the sartorius muscle, whose fibers are long and coming off of the iliac spine. It is a discrete muscle in its own fascial sheath that is easy to identify. If you do not see those fibers running from the anterior spine in a distal medial direction, but are seeing fibers only running longitudinally along the leg, then something is wrong. Once you are deep to the sartorius, you will see the longitudinal fibers of the rectus. The rectus muscle is in a discrete sheath, whose medial border protects the psoas tendon. You should see the longitudinal fibers of the rectus and the discrete sheath. If you are deep to the sartorius and you do not see them you are probably too far lateral. If you see fibers coming directly off of the proximal femur, you are looking at the origin of the vastus intermedius and are too far distal. If you see fibers running from the midline of the body toward the femur, you are looking at the pectineus muscle. Be careful, because the nerve, artery, and vein are just anterior to the pectineus.

FIGURE 31 — 1 The incision, with the anterosuperior iliac spine at the top.

FIGURE 3 1—2 The subcutaneous fat being retracted laterally; the fascia overlying the muscle is seen. The lateral femoral cutaneous nerve is usually proximal and lateral by the time you are in the subcutaneous tissue, because the incision starts 2 cm distal to the anterosuperior iliac spine. It can, however, come right across the middle of your incision.

FIGURE 31—3 The sartorius muscle. The tensor fascia lata muscle is lateral and still covered by fat.

D Anterosuperior Iliac Spine

Q Fascia Over Sartorius

D Interval Between Sartorius and Tensor

El Lateral Femoral Cutaneous Nerve

Q Femoral Nerve Under the Fat

Q Rectus Sheath d Tensor Fascia Lata

DO! Hip Capsule

IB Femoral Head

E Femoral Neck

[Q Femoral Nerve

IB Pectineus

IE Femoral Artery

FIGURE 3 1—4 The nerve and the interval between the sarto-rius and tensor are now readily apparent.

FIGURE 3 1—5 The sartorius muscle's medial border is as far medial as this approach should go. The femoral neurovascular structures are close to this border.

FIGURE 3 1—7 The rectus femoris tendon being opened and with the sartorius and tensor retracted. The psoas sheath is seen in the depth of the wound.

□ Lateral Femoral Cutaneous Nerve Q Femoral Nerve Under the Fat

FIGURE 31—6 The fat and fascia overlying the rectus muscle. The sartorius is retracted medially and the tensor fascia laterally.

D Anterosuperior Iliac Spine Q Fascia Over Sartorius Q Sartorius

D Interval Between Sartorius and Tensor

FIGURE 3 1—8 The reflected head of the rectus femoris coming onto the hip capsule. The main body of the rectus is retracted laterally and the sartorius medially. The psoas is now readily apparent.

FIGURE 31—9 The rectus being retracted medially. The reflected head has been removed from the capsule and the capsule of the hip joint is seen in the depth of the wound.

FIGURE 31 — 11 The femoral neck exposed and the femoral head visible at the top of the figure. The only muscle origin that was moved was the reflected head of the rectus femoris.

FIGURE 31 — 10 The hip has been opened, exposing the femoral neck.

FIGURE 31 — 11 The femoral neck exposed and the femoral head visible at the top of the figure. The only muscle origin that was moved was the reflected head of the rectus femoris.

Q Rectus Sheath [El Tensor Fascia Lata 01 Hip Capsule IE Femoral Head

03 Femoral Neck

D3 Femoral Nerve

[E Pectineus

IE Femoral Artery

FIGURE 31-12 The psoas tendon is seen with the rectus retracted now laterally. The sartorius, pectineus, and femoral neurovascular structures are retracted medially. Going medial to the psoas is dangerous.

FIGURE 3 1 — 14 The femoral artery medial to the nerve. The muscle that is seen is the sartorius.

FIGURE 31-12 The psoas tendon is seen with the rectus retracted now laterally. The sartorius, pectineus, and femoral neurovascular structures are retracted medially. Going medial to the psoas is dangerous.

FIGURE 3 1 — 14 The femoral artery medial to the nerve. The muscle that is seen is the sartorius.

FIGURE 31 — 13 The femoral nerve. If you are medial to the sartorius tendon sheath, you are going to run into the femoral nerve.

Anterosuperior Iliac Spine

B

Fascia Over Sartorius

B

Sartorius

B

Interval Between Sartorius and Tensor

B

Lateral Femoral Cutaneous Nerve

B

Femoral Nerve Under the Fat

B

Psoas

B

Rectus

B

Rectus Sheath

[E

Tensor Fascia Lata

m

Hip Capsule

EE

Femoral Head

m

Femoral Neck

m

Femoral Nerve

m

Pectineus

03

Femoral Artery

Was this article helpful?

0 0

Post a comment