Anatomy of the Limb 6 - Hip, Buttock and Thigh Flashcards
List the layers of fascia in the lower limb
- Superficial fascia - subcutaneous tissue
- Deep fascia - in the thigh, called the fascia lara
Where is the fascia lata?
- Extends from the pelvis down the leg underneath the skin like a stocking
- Thickened area laterally it forms the ilio-tibial tract
List the regions in the buttock, hip and thigh
- Gluteal
- Anterior compartment of the thigh
- Medial compartent of the thigh
- Posterior compartment of the thigh
List the muscles in the gluteal region
The gluteal muscles a. Gluteus maximus b. Gluteus medius c. Gluteus minimus (Tensor fasciae latae)
The short external rotators of the hip
a. Piriformis
b. Obturator Internus
c. The gemellus (superior and inferior)
d. Quadratus Femoris
What is the function of the gluteal muscles?
Extensors, abductors, and external rotators of the hip
List the muscles in the anterior compartment of the thigh
- Pectineus
- Ilio-psoas
- Tensor Fasciae Lata
- Sartorius
- Quadriceps femoris (Rectus Femoris, Vastus Medialis, Vastus Intermedius, Vastus Lateralis)
What is the function of the anterior compartment of the thigh?
- Hip flexors
- Knee extensors
List the muscles in the medial compartment of the thigh
- Adductor longus
- Adductor brevis
- Adductor magnus
- Gracilis
- Obturator externus
What is the function of the medial compartment of the thigh
Mainly hip adductors
List the muscles in the posterior compartment of the thigh
- Semimanosus
- Semitendinosus
- Biceps femoris
List the functions of the posterior compartment of the thigh
- Knee flexors
- Hip extensors
- Commonly known as hamstrings
What are the attachments, innervation and functions of the piriformis muscle?
- Anterior surface of sacrum between anterior sacral foramina to medial side of superior border of greater trochanter of femur anterior sacral foramina
- Supplied by S1 and S2
- Laterally rotates the extended femur at hip joint; abducts flexed femur at hip joint
What are the attachments, innervation and functions of the obturator internus?
- Anterolateral wall of true pelvis; deep surface of obturator membrane and surrounding bone to medial side of greater trochanter of femur
- Nerve to obturator internus (L5, S1)
- Laterally rotates the extended femur at hip joint; abducts flexed femur at hip joint
What are the attachments, innervation and functions of the gemellus superior?
- External surface of ischial spine to along length of superior surface of the obturator internus tendon and into the medial side of greater trochanter of femur with obturator internus tendon
- Nerve to obturator internus (L5, S1)
- Laterally rotates the extended femur at the hip joint, abducts flexed femur at hip joint
What are the attachments, innervation and functions of the gemellus inferior?
- Upper aspect of ischial tuberosity to along length of inferior surface of the obturator internus tendon and into the medial side of greater trochanter of femur with obturator internus tendon
- Nerve to quadratus femoris
- Laterally rotates the extended femur at hip joint; abducts flexed femur at hip joint
What are the attachments, innervation and functions of the quadratus femoris?
- Lateral aspect of the ischium just anterior to the ischial tuberosity to the quadrate tubercle on the intertrochanteric crest of the proximal femur
- Nerve to quadratus femoris (L5, S1)
- Laterally rotates femur at hip joint
What are the attachments, innervation and functions of the gluteus minimus?
- External surface of ilium between inferior and anterior gluteal lines to the linear facet on the anterolateral aspect of the greater trochanter
- Superior gluteal nerve (L4, L5, S1)
- Abducts femur at hip joint; holds pelvis secure over stance leg and prevents pelvic drop on the opposite swing side during walking; medially rotates thigh
What are the attachments, innervation and functions of the gluteus medius?
- External surface of ilium between anterior and posterior gluteal lines to the elongate facet on the lateral surface of the greater trochanter
- Superior gluteal nerve (L4, L5, S1)
- Abducts femur at hip joint; holds pelvis secure over stance leg and prevents pelvic drop on the opposite swing side during walking; medially rotates thigh
What are the attachments, innervation and functions of the gluteus maximus?
- Fascia covering gluteus medius, external surface of ilium behind posterior gluteal line, fascia of erector spinae, dorsal surface of lower sacrum, lateral margin of coccyx, external surface of sacrotuberous ligament to the posterior aspect of iliotibial tract of fascia lata and gluteal tuberosity of proximal femur
- Inferior gluteal nerve (L5, S1, S2)
- Powerful extensor of flexed femur at hip joint; lateral stabilizer of hip joint and knee joint; laterally rotates and abducts thigh
What are the attachments, innervation and functions of the tensor fasciae latae?
- Lateral aspect of crest of ilium between anterior superior iliac spine and tubercle of the crest to the illiotibial tract of the fascia lata
- Superior gluteal nerve
- Stabilises the knee in extension
What are the attachments, innervation and functions of the psoas major?
- Posterior abdominal wall (lumbar transverse processes, intervertebral discs, and adjacent bodies from TXII to LV and tendinous arches between these points) to the lesser trochanter of femur
- Anterior rami
- Flexes the thigh at the hip joint
What are the attachments, innervation and functions of the illiacus?
- Posterior abdominal wall
- Lesser trochanter of femur
- Femoral nerve
- Flexes the thigh at the hip joint
What are the attachments, innervation and function of the vastus medialis?
- Femur—medial part of intertrochanteric line, pectineal line, medial lip of the linea aspera, medial supracondylar line to the quadriceps femoris tendon and medial border of patella
- Femoral nerve
- Extends the leg at the knee joint
What are the attachments, innervation and function of the vastus intermedius?
- Upper two thirds of anterior and lateral surfaces of femur to the quadriceps femoris tendon, lateral margin of patella, and lateral condyle of tibia
- Femoral nerve
- Extends the leg at the knee joint
What are the attachments, innervation and function of the vastus lateralis?
- Femur—lateral part of intertrochanteric line, margin of greater trochanter, lateral margin of gluteal tuberosity, lateral lip of the linea aspera to the Quadriceps femoris tendon and lateral margin of patella
- Femoral nerve
- Extends the leg at the knee joint
What are the attachments, innervation and function of the rectus femoris?
- Straight head originates from the anterior inferior iliac spine; reflected head originates from the ilium just superior to the acetabulum to the quadraceps femoris tendon
- Femoral nerve
- Flexes the thigh at the hip joint and extends the leg at the knee joint
What are the attachments, innervation and function of the sartorius?
- Anterior superior iliac spine to the medial surface of tibia just inferomedial to tibial tuberosity
- Femoral nerve
- Flexes the thigh at the hip joint and the leg at the knee joint
What are the attachments, innervation and function of the gracilis?
- A line on the external surfaces of the body of the pubis, the inferior pubic ramus, and the ramus of the ischium to the medial surface of proximal shaft of tibia
- Obturator nerve
- Adducts thigh at the hip joint, flexes leg at knee joint
What are the attachments, innervation and function of the pectineous?
- Pectineal line (pecten pubis) and adjacent bone of pelvis to the oblique line extending from base of lesser trochanter to linea aspera on posterior surface of proximal femur
- Femoral nerve
- Adducts and flexes thigh at hip joint
What are the attachments, innervation and function of the adductor longus?
- External surface of body of pubis (triangular depression inferior to pubic crest and lateral to pubic symphysis) to the linea aspera on middle one-third of shaft of femur
- Obturator nerve
- Adducts and medially rotates thigh at hip joint
What are the attachments, innervation and function of the adductor brevis?
- External surface of body of pubis and inferior pubic ramus to posterior surface of proximal femur and upper one-third of linea aspera
- Obturator nerve
- Adducts and mediallly rotates thigh at hip joint
What are the attachments, innervation and function of the adductor part of the adductor magnus?
- From ischiopubic ramus to posterior surface proximal femur, linea aspera, medial supracondylar line
- Obturator nerve
- Adducts and medially rotates thigh at hip joint
What are the attachments, innervation and function of the hamstring part of the adductor magnus?
- Ischial tuberosity to the adductor tubercle and supracondylar line
- Sciatic nerve
- Adducts and medially rotates thigh at hip joint
What are the attachments, innervation and function of the obturator externus?
- External surface of obturator membrane and adjacent bone to the trochanteric fossa
- Obturator nerve
- Laterally rotates thigh at hip joint
What are the attachments, innervation and function of the biceps femoris?
- Long head - inferomedial part of the upper area of the ischial tuberosity, short head - lateral lip of linea asperal
- Distal attachment head of fibula
- Sciatic nerve
- Flexes leg at knee joint, extends and laterally rotates thigh at hip joint and laterally rotates leg at the knee joint
What are the attachments, innervation and function of the semitendinosus?
- Inferomedial part of the upper area of the ischial tuberosity to the medial surface of proximal tibia
- Sciatic nerve
- Flexes leg at knee joint and extends thigh at hip joint; medially rotates thigh at hip joint and leg at knee joint
What are the attachments, innervation and function of the semimembranosis?
- Superolateral impression on the ischial tuberosity to the groove and adjacent bone on medial and posterior surface of medial tibial condyle
- Sciatic nerve
- Flexes leg at knee joint and extends thigh at hip joint; medially rotates thigh at hip joint and leg at knee joint
List the borders of the femoral triangle
- Superiorly - inguinal ligament
- Medially - lateral edge of the adductor longus
- Laterally - medial edge of the sartorius
What is contained in the femoral triangle?
- Femoral nerve
- Femoral artery
- Femoral vein
What is the femoral sheath?
Encloses the femoral artery and vein but not nerve. Medially forms the femoral canal
What is the adductor canal?
- The adductor canal extends on the medial aspect of the thigh
from the apex of the femoral triangle and transmits the superficial
femoral artery and vein and the saphenous nerve. - It is formed by
the vastus medialis (anteriorly), the adductor longus and magnus
(posteriorly) and sartorius (medially)
List the important ligaments in the gluteal region
Sacrotuberous ligament and sacrospinous ligament (forms lesser and greater sciatic foramen)
What is in the lesser sciatic notch?
Structures passing from the pelvis to the perineum
What is in the greater sciatic notch?
Structures leaving the pelvis to the lower limb, including the sciatic nerve
Describe the passage of the sciatic nerve in the buttock and thigh
- Enters the gluteal region inferiorly to the piriformis muscle (normally)
- It passes through the greater sciatic notch to pass from the pelvis into the buttock.
- The nerve passes through the buttock and on the posterior aspect of the thigh to divide at a very inconstant level into the tibial nerve and the common
peroneal nerve. - The sciatic nerve itself supplies the hamstring muscles, while its divisions supply the muscles below the level of the knee
- Lies in inferior and medial quadrant of the buttock
What kind of joint is the hip joint?
Synovial ball and socket joint between the head of the femur and the acetabulum
What does the acetabulum consist of?
- Rim of tissue around the outside called the acetabular labrum
- Transverse acetabular ligament within the acetabulum
Describe the pathway of the capsule of the hip joint
- Extends down the neck of the femur
- Anteriorly extends further than posteriorly
- Within the capsule runs blood supply to the head of the femur
- Hip fractures may be intracapsular or extracapsular
List the important ligaments of the hip joint. Why are they important?
- The ilio-femoral ligament
- The pubo-femoral ligament
- The ischio-femoral ligament
(These are spirally arranged, and stabilise extension of the hip joint by pulling the head into the acetabulum) - The ligament of the head of the femur
Describe the blood supply of the hip joint
- Medial and
lateral circumflex arteries plus, insignificantly in the adult but
significant in the child, the artery of the head of the femur. - The circumflex vessels are the main blood supply in the adult and are easily damaged in intracapsular fractures of the proximal femur.
List the hip flexors
a. Ilio-psoas
b. Sartorius
c. Tensor fascia lata
d. Rectus femoris (part of quadriceps femoris)
e. Adductor longus
f. Adductor brevis
g. Anterior portion of adductor magnus
h. Gracilis
List the hip adductors
a. Adductor longus
b. Adductor brevis
c. Adductor magnus
d. Gracilis
e. Pectineus
f. Obturator Externus
List the hip extensors
a. The hamstrings – semitendinosus, semimembranosus,
biceps femoris
b. Posterior part of adductor magnus
c. Gluteus maximus
List the hip abductors
a. Gluteus medius
b. Gluteus minimus
c. Tensor fascia lata
List the hip external rotators
a. Obturator internus
b. Obturator externus
c. The gamelli
d. Piriformis
e. Quadratus femoris
f. Gluteus maximus
List the hip internal rotators
a. The anterior portion of gluteus medius
b. The anterior portion of gluteus minimus
c. Tensor fascia lata
Describe the arterial supply of the thigh and gluteal region
- The external iliac artery passes from the pelvis beneath the inguinal ligament and proceeds as the femoral artery.
- At the
level of the inguinal ligament the artery lies at the mid-inguinal point i.e. half-way between the ASIS and the pubic symphysis. - It is easily palpable here. It is lateral to the femoral vein and medial to the femoral nerve.
- The femoral artery then gives of the main branch to the thigh called the profunda femoris artery.
- At this level the femoral artery and its profunda branch give off the circumflex vessels, which supply the hip joint.
- The femoral artery continues after giving off the profunda femoris artery as the superifical femoral artery.
- At the level of the knee the superficial femoral artery becomes the popliteal artery.
Describe the venous drainage of the thigh and gluteal region
- In the thigh the main superficial vein is the long saphenous vein
(also known as the great saphenous vein). - It runs from the medial border of the foot, passes the knee on its medial aspect, passes up the medial aspect of the thigh to join the deep system at the sapheno-femoral junction. - There is an important valve at the sapheno-femoral junction that
prevents blood passing from the deep to the superficial system. - This valve is often faulty or incompetent in varicose veins.
- The deep veins of the thigh flow into the popliteal vein at the
level of the knee. - The popliteal vein runs along side the popliteal and femoral arteries to form the femoral vein.
- The femoral vein lies medial to the femoral artery in the groin, and then passes beneath the inguinal ligament to form the external iliac vein.
- The femoral vein receives the long saphenous vein at the saphenofemoral junction in the groin. Proximal to this it also receives the
venae comitantes of the profunda femoris artery
Describe the lymphatic drainage of the thigh and gluteal region
- Lymph flows with the superficial and deep venous systems.
- The superficial system runs with the long and short saphenous veins and has lymph nodes in the groin called the superficial inguinal lymph nodes.
- These drain to both the deep inguinal
lymph nodes and the external iliac lymph nodes. - The deep system of lymphatic drainage drains alongside the deep veins to the deep inguinal lymph nodes.
- These subsequently
drain into the external iliac lymph nodes.
Describe the motor segmental supply to the thigh muscles
- The Hip Flexors are in general supplied by L2 and L3
- The Hip Extensors are in general supplied by L4 and L5
- The Knee Extensors are in general supplied by L3 and L4
- The Knee Flexors are in general supplied by L5 and S1
Describe the motor peripheral supply
- The nerve of the anterior compartment of the thigh is the femoral nerve, which is derived from the posterior divisions of the lumbar plexus (L2, L3 and L4)
- The nerve of the medial compartment of the thigh is the
obturator nerve, which is derived from the anterior divisions of the lumbar plexus (L2, L3 and L4). - The nerve of the posterior compartment of the thigh is the sciatic
nerve, which is derived from the lumbo-sacral plexus (L345S12) - The nerves of the gluteal “compartment” are the superior and
inferior gluteal nerves. - The superior gluteal nerve (L45S1)
supplies the gluteus medius and gluteus minimus. - The inferior
gluteal nerve (L5S12) supplies the gluteus maximus
Describe the sensory segmental supply
- However in general the area at the front of the thigh is supplied by
T12, L1, L2 and L3 anteriorly and posteriorly by S1, S2 and S3. - The buttock is supplied by S2-4.
Describe the sensory peripheral supply
- Subcostal nerve (T12)
- Ilio-hypogastric nerve (L1)
- Ilio-inguinal nerve (L1)
- Genito-femoral nerve (L1 and L2)
- Lateral cutaneous nerve of the thigh (L2 and L3)
- Sensory branches of the femoral nerve (L2,L3 and L4)
- Sensory branches of the obturator nerve (L2, L3 and L4)
- Posterior cutaneous nerve of the thigh (S2 and S3)
- Saphenous nerve (terminal branch of the femoral nerve
(L234)
10.Buttock nerves derived from the sacral plexus ((L1 through
to S3)
Describe the twisting of the lower limb during development
- Everything below the hip joint is back to front, as during development there is permanent pronation of the leg from midthigh level
- Therefore flexion of the knee joint is posterior movement, while at the kip joint flexion is anterior movement
List the bones of the region
- Pelvis (ischium, ilium, pubic)
- Femur
What are the most common fractures of the hip?
- Fracture of the femoral neck
- Intertrochanteric fracture
What is the ilio-psoas muscle?
Formed from the psoas major and illiacus
What forms the patellar ligamanet?
Rectus femoris, vasctus intermedius, lateralis and medialis
What is the adductor hiatus?
Gap between the adductor magnus muscle and the femur that allows the passage of the femoral vessels from the anterior thigh to the posterior thigh and then the popliteal fossa.
Where does the great saphenous vein join the femoral vein?
Saphenous opening in the femoral triangle
Where is the safe area for IM injections?
The upper lateral quadrant of the buttock
What is the trendelenberg test?
- Abductors of the thigh prevent tilting of the pelvis when a limb is raised
- When paralysed, the hips will move when a leg is lifted
How can dermatomes be remembered?
L3 to the knee, L4 to the floor
What is the significance of true leg length and apparent leg length?
- True is from the medial malleolus of the ankle to the ASIS, looks for discrepancy in leg length
- Apparent is from the medial malleolus to the xiphisternum, looking at the effect of pelvic tilt
- If there is a difference in true leg length between the legs but not apparent, the pelvis is tilted to compensate for the difference in length (eg. hormonal issues, growth deformities, osteoarthritis)
- If there is a difference in apparent leg length but not true, then the pelvis is tilted abnormally (eg.scoliosis)
How is the gluteal region split into 4 quadrants?
- PSIS to greater tubercle is one line
- Summit of iliac crest down the length of the femur is another
