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Femoral triangle

The femoral triangle, also known as Scarpa's triangle, is a wedge-shaped intermuscular space situated in the superomedial aspect of the anterior thigh, immediately inferior to the inguinal ligament, and it appears most prominently when the hip is flexed, abducted, and externally rotated.^[1]^[2] It functions as a critical conduit for neurovascular structures passing from the pelvis into the lower limb, containing key elements such as the femoral nerve, femoral artery, femoral vein, and deep inguinal lymph nodes, enclosed within the femoral sheath.^[3] The triangle's boundaries include the inguinal ligament superiorly, the medial border of the sartorius muscle laterally, and the medial border of the adductor longus muscle medially, with its apex formed by the intersection of the sartorius and adductor longus.^[1] The floor consists of the pectineus and adductor longus muscles medially and the iliopsoas muscle laterally, while the roof is formed by the fascia lata overlying the skin and subcutaneous tissues.^[2] From lateral to medial, the contents of the femoral triangle are remembered by the mnemonic NAVEL (nerve, artery, vein, empty space of the femoral canal, and lymphatics), highlighting the femoral nerve's role in innervating the anterior thigh muscles and providing sensory input to the leg and foot, the femoral artery as the primary arterial supply to the lower limb, the femoral vein as the drainage pathway for the great saphenous vein, and the femoral canal housing deep inguinal lymph nodes and vessels.^[3] These structures lie within a fascial compartment known as the femoral sheath, which extends distally from the abdominal wall and facilitates the smooth passage of vessels and nerves.^[1] Clinically, the femoral triangle is significant for its accessibility to the femoral pulse at the mid-inguinal point, aiding in cardiovascular assessments, and serves as a common entry site for vascular procedures such as arterial catheterization, angioplasty, and venous access for central lines or dialysis.^[2] It is also prone to femoral hernias, where abdominal contents protrude through the femoral canal, potentially causing complications like bowel obstruction, and is relevant in staging malignancies due to the presence of lymph nodes that drain the lower limb and perineum.^[3] Additionally, the region is used in ultrasound-guided evaluations for conditions like abscesses, aneurysms, or vascular occlusions, such as those seen in Leriche syndrome, which involves aortoiliac atherosclerosis leading to symptoms like claudication and erectile dysfunction.^[1]

Anatomy

Location and boundaries

The femoral triangle, also known as Scarpa's triangle, is a triangular intermuscular space situated in the superomedial aspect of the anterior thigh.^[3]^[4] This region becomes visible as a superficial depression when the thigh is flexed, abducted, and laterally rotated.^[1] The superior boundary of the femoral triangle is defined by the inguinal ligament, which spans from the anterior superior iliac spine to the pubic tubercle.^[1]^[5] The medial boundary consists of the medial margin of the adductor longus muscle, while the lateral boundary is formed by the medial margin of the sartorius muscle.^[1]^[3] The apex occurs at the point where the sartorius muscle crosses over the adductor longus muscle and is continuous inferiorly with the adductor canal.^[1]^[6] It lies immediately inferior to the inguinal region, serving as a transitional area for lower limb structures.^[1]

Roof and floor

The roof of the femoral triangle consists of multiple layered structures that provide superficial covering to the region. Superficially, it is formed by the skin overlying the superficial fascia, which comprises two distinct layers: Camper's fascia, a fatty areolar layer containing adipose tissue and small vessels, and Scarpa's fascia, a deeper membranous layer of dense collagenous connective tissue that is thinner than Camper's and continuous with similar structures in the abdominal wall.^[7]^[8] Deep to these lies the fascia lata, the deep fascia of the thigh, which tightly invests the underlying muscles and forms the immediate deep boundary of the roof.^[1] Within the fascia lata, the saphenous opening—also known as the fossa ovalis—represents an oval-shaped defect, located superolaterally in the triangle. This opening is bridged and covered by the cribriform fascia, a sieve-like perforate extension of the superficial fascia that allows the passage of the great saphenous vein and associated lymphatic vessels from superficial to deep tissues while maintaining structural continuity.^[1]^[9] The roof's composition facilitates attachment of superficial cutaneous structures, such as skin ligaments, and its relatively thin, multi-layered nature contributes to regional vulnerability, particularly at the saphenous opening.^[1] The floor of the femoral triangle forms a sloped, oblique muscular plane that inclines medially and inferiorly, providing a firm base for the overlying structures. Medially, it is composed of the pectineus muscle, which originates from the pectineal line of the pubis and inserts on the femur, and the adductor longus muscle, arising from the pubis and contributing to thigh adduction. Laterally, the floor is formed by the iliopsoas muscle group, consisting of the iliacus muscle (originating from the iliac fossa) and the psoas major muscle (arising from the lumbar vertebrae), which together flex the hip joint.^[1] This arrangement of muscles ensures stability and support within the triangle, defined superiorly by the inguinal ligament and inferiorly by the sartorius and adductor longus tendons.^[1]

The femoral triangle houses critical neurovascular and lymphatic structures essential for lower limb perfusion, innervation, and drainage, arranged primarily from lateral to medial within its boundaries. These contents are enclosed variably by the femoral sheath, a fascial extension from the abdomen, and include the femoral nerve laterally, followed by the femoral artery, femoral vein, femoral canal, and deep inguinal lymph nodes medially.^[1]^[3] A common mnemonic to recall this lateral-to-medial order is "NAVEL": Nerve (femoral nerve branches), Artery (femoral artery), Vein (femoral vein), Empty space (femoral canal), Lymphatics (deep inguinal lymph nodes).^[10]^[1] The femoral nerve, the largest branch of the lumbar plexus (from anterior rami of L2-L4), enters the femoral triangle deep to the inguinal ligament and lies lateral to the femoral vessels. Within the triangle, it divides into anterior and posterior divisions; the anterior division supplies the nerve to pectineus (innervating the pectineus muscle) and gives rise to the medial cutaneous nerve of the thigh, while the posterior division provides motor branches including the nerve to vastus medialis (innervating the vastus medialis muscle) and the saphenous nerve (for medial leg sensation). The lateral cutaneous nerve of the thigh, arising separately from L2-L3, passes under the inguinal ligament lateral to the femoral nerve and sartorius muscle, descends along the anterolateral thigh, and pierces the fascia lata approximately 10 cm inferior to the inguinal ligament, providing sensory innervation to the anterolateral thigh. It lies outside the femoral triangle. The femoral nerve itself is not enclosed by the femoral sheath.^[11]^[1]^[12] The femoral sheath divides the medial portion of the triangle into three compartments around the proximal femoral vessels. The lateral compartment contains the femoral artery—a continuation of the external iliac artery—and the femoral branch of the genitofemoral nerve (providing sensory innervation to the femoral region skin). The intermediate compartment encloses the femoral vein, a tributary of the external iliac vein. The medial compartment, known as the femoral canal, is the smallest and contains loose connective tissue, lymphatic vessels, and Cloquet's node (also called Rosenmüller's node), a proximal deep inguinal lymph node embedded in fatty areolar tissue. The proximal parts of the profunda femoris artery (deep artery of the thigh) and its accompanying vein originate within the triangle from the posterolateral aspect of the femoral artery and vein, respectively, approximately 3.5-5 cm distal to the inguinal ligament, before passing posteriorly to supply the thigh muscles.^[1]^[3] The deep inguinal lymph nodes, numbering 4-5, lie along the medial and anterior aspects of the femoral vein within the triangle and receive lymphatic drainage from the lower limb, perineum, and superficial inguinal nodes before efferent vessels ascend to the external iliac nodes. Cloquet's node, the most superior of these, is positioned at the apex of the femoral canal just inferior to the inguinal ligament and serves as a key relay point in this drainage pathway.^[1]^[13]

Clinical significance

Femoral hernias

A femoral hernia represents a protrusion of abdominal contents, such as omentum or small intestine, through the femoral canal, which forms the medial compartment of the femoral sheath in the femoral triangle. This defect is bounded medially by the lacunar ligament, posteriorly by the pectineal (Cooper's) ligament, and anteriorly by the inguinal ligament, creating a narrow passage prone to entrapment.^[14] Unlike inguinal hernias, femoral hernias emerge inferior to the inguinal ligament, directly involving the structures of the femoral triangle.^[14] Femoral hernias comprise about 3% of all groin hernias and occur more frequently in females, with a female-to-male ratio of approximately 4:1, due to anatomical differences including a wider pelvis and shallower femoral canal that facilitate herniation.^[14]^[15] Key risk factors include obesity, pregnancy, advanced age, chronic increased intra-abdominal pressure from conditions like constipation or chronic cough, and connective tissue disorders, all of which weaken the canal's supportive structures.^[14] Clinically, patients often present with a small, firm lump in the groin below the inguinal ligament, positioned more medially than an inguinal hernia, which may become more prominent with standing, coughing, or straining.^[14] Up to one-third of cases are asymptomatic until complications arise, but symptoms can include localized pain, discomfort during walking, or signs of bowel obstruction such as nausea and vomiting if incarcerated.^[14] These hernias carry a high risk of serious complications, with strangulation occurring in approximately 22% of cases within three months and up to 45% over two years if untreated, and an overall strangulation rate of 15-20%, potentially leading to bowel ischemia, perforation, or sepsis if not addressed promptly.^[14]^[16] Diagnosis relies primarily on physical examination, where an expansile cough impulse is elicited below the inguinal ligament in the supine and standing positions, distinguishing it from other groin masses.^[14] Confirmation via ultrasound, which offers high sensitivity for detecting the hernia sac and contents, or computed tomography (CT) scan is recommended for obese patients, equivocal exams, or suspected complications like strangulation.^[14] Treatment is surgical, as watchful waiting is not advised due to the elevated complication risk; elective repair is preferred for asymptomatic cases, while emergency intervention is mandatory for incarceration or strangulation.^[14] Open surgical approaches include the McVay technique, which sutures the inguinal ligament to the pectineal ligament for reinforcement, and the Bassini method, involving transposition of the sac and tissue approximation, both commonly augmented with synthetic mesh to lower recurrence rates to under 4%.^[14]^[17] Laparoscopic options, such as the totally extraperitoneal (TEP) or transabdominal preperitoneal (TAPP) repairs, provide minimally invasive alternatives with mesh placement, achieving recurrence rates below 1% in elective settings and facilitating quicker recovery, particularly for bilateral hernias.^[14] In contaminated cases from strangulation, non-mesh repairs may be used initially, followed by delayed mesh reinforcement.^[14]

Vascular and neural access

The femoral pulse is typically palpated at the midpoint of the inguinal ligament, corresponding to the mid-inguinal point between the anterior superior iliac spine and the pubic symphysis, to enable rapid vascular assessment in emergencies such as cardiac arrest where peripheral pulses may be impalpable.^[18] This location aligns with the common femoral artery's position within the femoral triangle, facilitating quick identification for resuscitation protocols.^[19] Arterial access via the femoral artery is commonly achieved using the Seldinger technique, involving percutaneous needle puncture followed by guidewire insertion and catheter advancement, for procedures such as coronary angiography or percutaneous coronary intervention (PCI). The optimal puncture site is 1-2 cm below the inguinal ligament over the common femoral artery, which lies lateral to the femoral vein within the femoral sheath, to minimize risks of retroperitoneal bleeding or vessel occlusion.^[20] Ultrasound guidance is increasingly recommended to confirm vessel patency and depth, enhancing procedural safety.^[21] Femoral vein cannulation provides central venous access for hemodynamic monitoring, fluid resuscitation, or medication administration, with the needle inserted 1 cm medial to the femoral arterial pulse at a 30-45 degree angle under ultrasound guidance to avoid inadvertent arterial puncture.^[22] This real-time imaging reduces mechanical complications by visualizing the vein's position medial to the artery within the sheath.^[1] Common complications include hematoma formation, occurring in approximately 5% of cases without guidance, and catheter-related infections, with rates varying from 1-5 per 1000 catheter-days depending on dwell time and aseptic technique.^[23]^[24] The femoral nerve block involves injecting 10-20 mL of local anesthetic, such as ropivacaine or bupivacaine, around the nerve sheath using ultrasound guidance, typically 1-2 cm distal to the inguinal ligament but proximal to the nerve's division into anterior and posterior branches within the femoral triangle.^[25] This technique provides effective analgesia and anesthesia for lower extremity procedures, including total knee arthroplasty and hip fracture repair, by blocking sensory and motor innervation to the anterior thigh and knee.^[26] It offers advantages over systemic opioids, including reduced postoperative pain scores and faster mobilization.^[27] Historically, femoral arterial puncture was first described in the 19th century as a method for bloodletting to treat conditions like inflammation and fever, predating modern catheterization techniques.^[28]

Lymphatic evaluation and surgery

The deep inguinal lymph nodes, located within the femoral triangle medial to the femoral vein, receive lymphatic afferents from the lower limb, perineum, and external genitalia, including the glans penis or clitoris, as well as from the superficial inguinal nodes.^[29]^[1] These nodes play a critical role in draining lymphatic fluid from these regions, with their efferent vessels primarily directing flow to the external iliac nodes, which may also receive direct afferents from the superficial inguinal group.^[30] Cloquet's node, the most proximal deep inguinal lymph node situated in the femoral canal, serves as a key sentinel structure for detecting pelvic metastasis, particularly in malignancies such as penile cancer.^[31] Metastatic involvement of Cloquet's node exhibits a high positive predictive value—up to 100% in some studies—for deep pelvic lymph node involvement, making it a superior indicator compared to radiological imaging alone for guiding the extent of dissection.^[32]^[33] Lymphatic evaluation in the femoral triangle typically involves fine-needle aspiration (FNA) or excisional biopsy of suspicious deep inguinal nodes to stage cancers like melanoma or penile squamous cell carcinoma, confirming metastasis prior to definitive surgery.^[34]^[35] In penile carcinoma, FNA of palpable nodes predicts inguinal metastasis with high accuracy, often without requiring antibiotic pretreatment, while in melanoma, it enables outpatient sampling for cytological assessment.^[30] These minimally invasive techniques help determine the need for lymphadenectomy while minimizing procedural risks. Surgical management centers on inguinal lymphadenectomy, which encompasses both superficial and deep dissections within the femoral triangle to address metastatic disease.^[30] Preservation of the saphenous vein during these procedures significantly reduces the incidence of postoperative lymphedema and other complications without compromising oncologic outcomes, as evidenced by multiple retrospective studies.^[36]^[37] If Cloquet's node is positive for metastasis, a radical ilioinguinal dissection—extending to pelvic nodes—is indicated to improve regional control and survival, with 5-year rates around 25-50% for advanced nodal disease in penile cancer.^[38] Common complications of inguinal lymphadenectomy include lymphedema, affecting 20–30% of patients, and wound infections, with rates ranging from 5–15% depending on surgical technique and patient factors.^[39]^[40] Lymphedema risk increases with removal of 10 or more nodes or extensive dissection, while infections often necessitate antibiotics.^[41] Postoperative care emphasizes compression therapy, early mobilization, and wound monitoring to mitigate these issues and promote lymphatic regeneration.^[42]

Imaging and variations

Ultrasound serves as the first-line imaging modality for evaluating the femoral triangle, particularly for assessing the femoral vessels, detecting hernias, or identifying hematomas, with Doppler ultrasonography enabling real-time assessment of blood flow dynamics.^[43] The procedure typically involves placing a high-frequency linear transducer along the inguinal ligament in both transverse and longitudinal orientations to visualize the femoral sheath compartments and surrounding structures.^[43] Early sonographic studies from the 1980s demonstrated its utility in diagnosing entities such as abscesses and fluid collections in the femoral triangle, marking a shift from plain radiography's limitations in soft tissue depiction.^[44] Computed tomography (CT) and magnetic resonance imaging (MRI) provide detailed evaluation of soft tissues within the femoral triangle, especially in cases of trauma, tumors, or suspected sheath compartment involvement, with CT excelling in vascular enhancement and MRI offering superior contrast for neural and muscular elements.^[45] Multidetector CT reconstructions, particularly coronal views, delineate the radiologic femoral triangle, highlighting the femoral canal and potential node enlargement.^[45] These modalities, introduced in the 1970s and refined through the 1980s, have evolved to support comprehensive assessment of groin pathologies, including inguinal and femoral masses.^[46] Anatomical variations in the femoral triangle include differences in femoral canal width, which is generally narrower in males than in females, contributing to gender-specific risks such as higher hernia incidence in females due to wider pelvic dimensions. Aberrant branching of the femoral nerve can occur, often involving early division or accessory branches within the triangle, potentially complicating neural identification.^[47] Accessory lymph nodes may also be present, altering lymphatic drainage patterns. High bifurcation of the femoral artery, defined as occurring proximal to the usual level below the inguinal ligament, has an incidence of about 26-30%, with very high origins in 4% of cases, detectable via preoperative imaging to mitigate procedural risks.^[48] These variations carry clinical implications, as a wider femoral canal predisposes to hernias, while aberrant nerve branching or high arterial bifurcations elevate risks during vascular interventions, such as unintended puncture or nerve injury. Imaging plays a crucial role in preoperative planning, identifying high bifurcations to guide safe access and reducing complication rates in procedures involving the femoral triangle.^[49]

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