Gluteal Region Flashcards
boundaries of the gluteal region
iliac crest, intergluteal cleft (natal cleft), gluteal fold
How is the femur adapted in regards to our center of gravity
they are oblique so that they can be as close to the center of gravity axis as possible. midline.
where is our center of gravity really located?
L5
Coxa valga
when the angle between the head and neck of the femur (medial) is larger that 135
Coxa Vara
when the angle between the head and neck of the femur is less than 120
coxa norma
when the angle between the head and neck of the femur is between 135 and 120
True (lesser) pelvis vs false (greater) pelvis
false pelvis contains abdominal viscera and extends from the iliac crest down to the pelvic brim. The true pelvis extends from the pelvic brim to the perenium and contains our reproductive organs.
which 3 bones make up the os coxae
ilium, ischium and pubis
whats special about the os coxae?
the three bones are connected by triradiate cartialge during childhood (black on radiograph). the three bones begin to fuse (where the Y shaped triradiate cartilage is) around puberty.
Important features of the os coxae
greater sciatic notch, ischial spine, lesser sciatic notch, ischial tuberosity, acetabulum, pubic tubercle, anterior inferior iliac spine, anterior superior iliac spine, posterior superior iliac spine, posterior inferior iliac spine, obturator groove, pectineal line, superior pubic ramus, inferior pubic ramus, ramus of ischium, body of ischium. gluteal lines (all three)
More to know for the bones
greater sciatic foramen, lesser sciatic foramen, sacrospinous ligament, sacrotuberous ligament, obturator foramen, margin of pelvic inlet
which ligament separates the greater sciatic foramen form the lesser sciatic foramen?
sacrospinous ligament which connects the sacrum to the ischial spine
which ligament connects the sacrum to the ischial tuberosity?
sacrotuberous liagment
what passes through the lesser sciatic foramen?
obturator internus muscle tendon, nerve to obturator internus muscle, internal pudendal vessels, pudendal nerve
what passes through the Greater sciatic foramen
piriformis muscles fills the foramen; provides pathway for superior and inferior gluteal vessels and nerves, internal pudendal vessels, pudendal nerve, posterior femoral cutaneous nerve, nerves to obturator internus and quadratis femoris muscle.
inguinal ligament attachement
anterior superior iliac crest to the pubic tubercle
what runs under the inguinal ligament
femoral artery (runs down), femoral vein (runs up), femoral nerve
what type of joint is the sacroiliac joint?
synovial
differences between male and female pelvis?
female=circular pelvic inlet and wider angle between the pubic symphysis
Male=heart shaped pelvic inlet and smaller angle between pubic symphysis
How is the length of the femur related to height?
height=femur length x 4
know the following femur bone structures
Head, neck, greater trochanter, lesser trochanter, angle of inclination, intertrochanteric line, shaft, lateral epicondyle, lateral condyle, patellar surface, medial condyle, medial epicondyle, adductor tubercle, fovea for ligament of head, trochanteric fossa, intertrochanteric crest, quadrate tubercle, pectineal line, spiral line, gluteal tuberosity, lateral and medial lips of the linea aspera, medial and lateral supracondylar line, popliteal surface, adductor tubercle, medial and lateral epicondyles, intercondylar line, medial and lateral condyles, intercondylar fossa
What attaches to the adductor tubercle?
the hamstring portion of the adductor magnus
what is on the head, patellar surface and medial and lateral condyles of the femur?
articulate cartilage
What attaches to the greater trochanter?
insertion site of the gluteus medius, gluteus minimus, piriformis and obturator internus
what attaches to the lesser trochanter?
insertion of the common tendon of the psoas major and iliacus (iliopsoas muscle)
what attaches to pectinal line?
it is inferior and continuous with the lesser trochanter. there are two pectineal lines (pecten pubis and femur) related to attachements of pectineus muscle.
what attaches to the trochanteric fossa
obturator externus tendon
what attaches to the intertrochanteric crest
(its on the posterior surface of the femur) and connects the greater and lesser trochanter. That quadratus femoris muscle inserts on the intertrochanteric crest at the quadrate tubercle
what attaches to the intertrochanteric line?
on the anterior femur from greater trochanter and descending downward towards lesser, capsule of hip joint attaches; continues as spiral line.
what attaches to the gluteal tuberosity?
distal attachment of glut max
what attaches to the linea aspera?
medial lip derived from spiral line. lateral lip descends from gluteal tuberosity. they form the medial and lateral supracondylar lines. Medial line ends at adductor tubercle, proximal to medial epicondyle. lateral line ends at lateral condyle of femur
what part of the femoral head is not covered in cartilage and why?
the fovea capitis because it attaches the ligamentum teres and transmits the acetabular branch of the obturator artery to the femoral head (the artery to the fovea travels through the ligamentum teres as its not a true ligament but folds of connective tissue)
what ligament spans the acetabular notch?
the transverse ligament
what is the acetabular labrum?
its a ring of cartilage that surrounds and deepens the acetabulum
which arteries supply blood to the head of the femur?
the circumflex arteries (most importantly the medial femoral circumflex artery)
what would happen if the neck of the femur was fractured?
blood supply to the head would be interrupted leading to avascular necrosis of the femoral head and arthritis
name the pathway of blood to the head of the femur
common iliac artery–>external iliac artery–>deep femoral artery of the thigh–>medial and lateral branches of the circumflex artery
once the external iliac artery goes underneath the inguinal ligament it is now called the…
femoral artery
the deep femoral artery, while it provides the medial circumflex artery that supplies blood to the head of the femur it also gives off…
perforating branches which perforate the muscles to go supply blood to the posterior side of the femoral region
***so posterior blood supply comes from the anterior
fractures of the femoral neck present how?
shortness and lateral rotation of the lower limb
what are the results of arthritis of the hip?
osteophytes and eroded articular cartilage
a femoral neck Fx usually requires
hip replacement (arthroplasty)
what about intertrochanteric Fxs?
lower than the femoral neck, bone blood flow remains intact, do not require hip replacements
how many cluneal nerves are there and where do they come from?
superior cluneal nerves: from the dorsal rami of L1-L3
medial cluneal nerves: from dorsal rami of S1-S3
inferior cluneal nerves: ventral rami and comes from the gluteal branch of the posterior femoral cutaneous nerve
the posterior femoral cutaneous nerve is located medially to the sciatic nerve.
the superior cluneal nerves come over the iliac crest
the medial cluneal nerves come from the sacral foramina and come over the gluteus max
the inferior cluneal nerves come from the posterior femoral cutaneous nerve which comes from just below the piriformis muscle
name the cutaneous nerves
lateral femoral cutaneous nerve, anterior cutaneous branch of femoral nerve, cutaneous branch of obturator nerve, saphenous nerve, lateral sural cutaneous nerve, sural nerve
A disorder that occurs when lateral femoral cutaneous nerve is compressed
Meralgia Paresthetica (CK syndrome or tingling thigh syndrome)
1st layer of gluteal muscles
gluteus max
2nd layer
medius, piriformis (with sciatic coming out from underneath it) and quadratis femoris
The inferior half of the deep part of the gluteus maximus attaches to…
the gluteal tuberosity
Glut max OINA
O: ilium posterior to posterior gluteal line; dorsal surface of sacrum and coccyx; sacrotuberous ligament
I: IT band (which inserts into lateral condyle of tibia; some fibers insert on gluteal tuberosity
N: inferior gluteal nerve (S1,S2)
A: extends thigh and laterally rotates (assists in rising from sitting position)
Glut medius OINA
O: external surface of ilium between anterior and posterior gluteal lines
I: lateral surface of greater trochanter of femur
N: superior gluteal nerve (L5, S1)
A: abduct and medially rotate thigh. Keeps pelvis level when ipsilateral limb is weightbearing
Glut min OINA
O: external surface of ilium between anterior and inferior gluteal lines
I: anterior surface of greater trochanter of femur
N: superior gluteal nerve
A: same as glut med
Tensor fasciae latae OINA
O: anterior superior iliac spine; anterior part of iliac crest
I: IT band
N: superior gluteal nerve
A: same as glut med
piriformis OINA
O: anterior surface of sacrum; sacrotuberous ligament
I: superior border of greater trochanter of femur
N: branches of anterior rami of S1 and S2
A: laterally rotate, extend thigh and abduct flexed thigh. Steady femoral head in acetabulum
Obturator internus OINA
O: pelvic surface of obturator membrane and surrounding bones
I: medial surface of greater trochanter (trochanteric fossa) of femur
N: nerve to obturator internus (L5, S1)
A: same as piriformis
Superior and inferior gemelli OINA
O: superior: ischial spine
Inferior: ischial tuberosity
I: Medial surface of greater trochanter (trochanteric fossa of femur)
N: superior: same as obturator internus
Inferior: same as quadratis femoris
A: same as piriformis
Quadratus femoris OINA
O: lateral border of ischial tuberosity
I: quadrate tubercle on intertrochanteric crest of femur and area inferior to it
N: nerve to quadratus femoris (L5, S1)
A: laterally rotates thigh, steadies femoral head in acetabulum
The most anterior of the gluteal muscles is the…
TFL
Arteries to the TFL
superior gluteal artery and the lateral femoral circumflex artery
IT band syndrome
IT band not attached to bone as it courses between Gerdy’s tubercle and the lateral femoral epicondyle. Allows for movement anteriorly and posteriorly with knee flexion and extension. causes rubbing against lateral femoral condyle
Gluteus minimus is deep to…
glut med
Paralysis of glut max does not affect…
walking on level ground
Damage to the superior gluteal nerve affects which muscles and produces which signs?
TFL, glut medius and minimus. signs are Trendelenburg gait and Trendelenburg sign
Trendelenburg gait
downward tilting of hip on non weight bearing side due to inability of glut med and min to actively abduct the hip on the weight bearing side during walking.
Trendelenburg sign
clinical test to determine the integrity of the superior gluteal nerve. Pt’s hip tilts down when the limb is not weight bearing because the superior gluteal nerve is damaged on the weight bearing side
the superior gluteal n. a. and v. emerge from
suprapiriform foramen (and can be seen under the reflected glut med muscle)
the pudendal nerve and internal pudendal a. and v. emerge from
infrapiriform foramen
inferior gluteal n, a, v emerge from
infrapiriform foramen
the sciatic nerve and the posterior femoral cutaneous nerve emerge…
together
The common iliac artery becomes…
the internal and external iliac artery before passing deep to the inguinal ligament
the internal iliac artery becomes the…
gluteal arteries, internal pudendal (perenium and external genitalia) and the obturator artery (adductor muscles)
The external iliac artery becomes the…
femoral artery has a branch that becomes the deep femoral (adductors, hamstrings, quadriceps).
The femoral artery continues down, through the adductor canal and out through the adductor hiatus to become the popliteal artery. The popliteal artery then becomes the genicular artery (knee), anterior tibial (ant. leg muscles with farther branches to feet) and the posterior tibial artery (flexor muscles, plantar arch, branches to toes)
What muscles make up the pelvic diaphragm?
piriformis, obturator internus, levator ani (iliococcygeus muscle, pubococcygeus muscle, puborectalis muscle), coccygous muscle, anal aperture, urogenital hiatus
how to remember the lateral rotators from top to bottom
Play Golf Or Go On Quaaludes (piriformis, gemellus superior, obturator internus, gemellus inferior, obturator externus, quadratis femoris; also gluteus maximus
suprapiriform foramen
superior gluteal n, a, v
infrapiriform foramen
inferior gluteal nav pudendal nav internal pudendal a v sciatic n posterior femoral cut. n
piriformis syndrome
neuromuscular disorder involves compressed sciatic n or aggravation caused by piriformis m. causes pain, tingling and numbness in the gluteal region and the sciatic nerve path down the lower thigh and leg
Positive piriformis sign
ipsilateral foot is externally rotated
What quadrant of the buttock is safest for intramuscular injection?
upper outer quadrant because its farthest from sciatic n
obturator externus OINA
O:outer surface of obturator membrane, superior and inferior pubic rami (deep to quadratus femoris)
I: trochanteric fossa
A: adduction and external rotation of the hip
N: obturator nerve
bursae of the hip
ischial, iliopsoas, greater trochanteric
see slide 55
see slide 55
see note on how to do shortcut for the sacral plexus
see note on how to do shortcut (SIPPS)
SIPPS
superior glut n inferior glut n post fem cut n pudendal n sciatic n
The sciatic nerve is actually made up of two nerves
the tibial nerve (goes medial) and the common fibular (peroneal) nerve (goes laterally)
tibial nerve
(L4, L5, S1-3)-all hamstrings except short head of biceps femoris and enters leg to supply the posterior leg and plantar foot
common fibular nerve
L4, L5, S1, S2-short head of the biceps femoris, lateral and anterior leg and dorsal foot
the sacroiliac joint
is synovial and fibrous (a compound synovial joint because it anteriorly involves cartilage covered articular surfaces within an encapsulated synovial cavity and a posteriorly a syndesmosis of powerful ligaments.
both facets of the joint are rugose to prevent slippage.
anterior sacroiliac ligament
connected to anterior surfaces of ilium and sacrum
posterior sacroiliac ligament
posterior superior iliac spine to the posterior aspect of the sacrum (very strong)
interosseous sacroiliac ligament
short and deep transverse fibers attached to the iliac and sacral tuberosities in between the bones (very strong)
sacrotuberous and sacrospinous ligaments
not directly connected to the SI joint but are essential in its control
the SI joint is a
shock absorber with only enough motion to tilt the pelvis
The hip joint parts
acetabulum, lunate surface, acetabular fossa, synovial membrane, synovial fluid
lunate surface
the part of the acetabulum that articulates with the head of the femur. covered with articulate cartilage
acetabular fossa
non-articular, inside the C which contains a fat pad and vessels
synovial membrane
internal lining of capsule and all other non-articulating internal joint structures, produces synovial fluid, contains blood supply, sensory innervation and is subject to inflammation. the membrane does not cover weight bearing articulating surfaces
synovial fluid
lubricates the articular surfaces
transverse acetabular ligament
attached to the opposite margins of the lunate C shaped articular area. Bridges the acetabular notch (allows acetabular artery to get inside the joint) continuous with acetabular labrum
ligament of the head of femur (ligamentum teres capitis femoris)
attached to the fovea on femoral head; its wide end attached to the transverse ligament and acetabular notch. Transmits small artery to the head
hip joint capsule
attached to acetabular rim, edge of labrum and transverse ligament. anteriorly, it extends to intertrochanteric line, posteriorly to the femoral neck. Not attached to trochanters of the intertrochanteric crest. its lined by synovial membrane
*the reflected capsule fibers along with the synovial lining form the retinacluae which enclose the blood vessels surrounding the neck
3 important ligaments
- iliofemoral (ligament of bigelow) strongest ligament in the body
- ischiofemoral ligament
- pubofemoral ligament
iliofemoral ligament
AIIS to intertrochanteric line where it blends with joint capsule. Resists medial and lateral rotation
Ischiofemoral ligament
ischial body at the acetabular rim and curves superolaterally to attach to femoral neck
weakest of extrinsic ligaments
tightens during extension
pubofemoral ligament
attached to pelvic bone and femur
inferior reinforcement of the hip
tightens during extension and abduction
iliofemoral ligament is particularly important…
in standing when it resists backward rotation of the trunk on the femur. it maintains upright posture at the hip joint without enlisting muscles
posterior hip dislocation
flexed, internally rotates and adducted
