C. The profunda fenioris artery branches into the:

1. Four perforating arteries

2. Medial circumflex artery, which provides the main blood supply to the head and neck of the femur in adults

3. Lateral circumflex artery

D. The popliteal artery is a continuation of the femoral artery at the adductor hiatus in the adductor magnus muscle. It extends through the popliteal fossa, where the popliteal pulse can be palpated against the popliteus muscle with the leg flexed. It has the following branches:

1. Genicular arteries

2. Anterior Tibial artery descends on the anterior surface of the interosseous membrane with the deep peroneal nerve and terminates as the dorsalis pedis artery. The dorsalis pedis artery lies between the extensor hallucis longus and extensor digitorum longus tendons midway between the medial and lateral malleolus where the dorsal pedal pulse can be palpated.

3. Posterior Tibial artery passes behind the medial malleolus with the tibial nerve where it can be palpated. The posterior tibial artery gives off the following branches:

a. Peroneal artery, which passes behind the lateral malleolus b. Medial plantar artery c. Lateral plantar artery, which forms the plantar arch, which connects to the dorsalis pedis artery

E. Collateral circulation

1. Around the hip joint (cruciate anastomosis). Circulation in this area involves the inferior gluteal artery (a branch of the internal iliac artery), the medial and lateral femoral circumflex arteries, and the first perforating branch of the profundus femoris artery.

2. Around the head of the femur (trochanteric anastomosis). Circulation in this area involves the superior and inferior gluteal arteries and the medial and lateral femoral circumflex arteries.

F. Clinical considerations

1. Acute arterial occlusion most commonly is caused by embolism or thrombosis. It usually occurs where the femoral artery gives off the profunda femoris artery. Clinical signs include the 6 P's: pain, paralysis, paresthesia, pallor, poikilothermia, and pulselessness. Acute arterial occlusion may lead to loss of the lower limb. If the occlusion is not treated promptly, damage to muscle and nerve (both of which are susceptible to anoxia) may occur within 4—8 hours.

2. Chronic arterial occlusive disease most commonly is caused by atherosclerosis.

a. General features. Chronic occlusion usually involves the femoral artery near the adductor hiatus and popliteal artery (femoropopliteal in 50% of cases). However, in diabetic patients, the anterior tibial artery, posterior tibial artery, and peroneal artery are susceptible to chronic occlusion.

b. Clinical signs include: intermittent claudication, the key feature of which is profound fatigue or aching on exertion (but never after sitting or standing for prolonged periods) that is relieved by short periods of rest (5-10 minutes); ischemic rest pain across the distal foot and toes, which usually occurs at night and awakens the patient. The pain is exacerbated by elevation and relieved by keeping the limb in a dependent position (e.g., sleeping with the leg over the side of the bed).

3. Compartment syndrome is an increase in the interstitial fluid pressure (^ 30 mm Hg) within an osseofascial compartment. This increased pressure compromises microcirculation (ischemia) and leads to muscle and nerve damage.

a. General features. Compartment syndrome most often occurs in the anterior compartment of the thigh as a result of crush injuries (e.g., in a car accident) involving the femoral artery and femoral nerve. It also occurs in the anterior compartment of the leg as a result of tibial fractures involving the anterior tibial artery and deep peroneal nerve, b. Clinical signs include: a swollen, tense compartment; pain on passive stretching of the tendons within the compartment; pink color; warmth; and the presence of a pulse over the involved compartment.

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