Hip, buttock and thigh Flashcards
What occurs during development to the lower limb
Twisting of the lower limb during development:
permanent pronation at the mid-thigh level
What are the two regions of the lower limb
The gluteal region (part of the trunk)
and
the “free lower limb” (thigh, leg and foot)
Which movements can happen at the hip
flexion (L2/3), extension (L4/5) lateral external rotation (L5,L1), medial internal rotation (L123), Adduction (L1-4), Abduction (L5,S1)
By how many degrees can the hip laterally and medially rotate
Medial internal rotation: 50 degrees
Lateral external rotation: 40 degrees
What are the bones in this region of the lower limb
The pelvis (the “hip bone”) -Ischium -Ilium -pubis The femur
At what age is the synostosis complete
This is between the ischium and the pubis…
at age 9 is completed
What is the name of the cartilage within the acetabulum
The triradiate cartilage
What is the name of the surface where the sacrum and the pelvic bone meet
Auricular surface
What makes up the acetabulum
Articular (lunate) surface and the acetabular fossa
What is the angle of inclination
Angle between the long axis of the shaft and the long axis of the head/neck of the femur
Which occurs more laterally, a fracture of the femoral neck, or a intertrochanteric frature
Intratrochanteric fracture is more lateral. This effectively marks the end of the neck of the femor
Which two ligaments are involved in the formation of the greater and the lesser sciatic foramina
Sacrotuberous and sacrospinous….
appreaciate how these work and how the lesser leads back into the pelvis
Which structures pass through the leser sciatic foramen
The pudendal nerve, the internal pudendal vessels and the tendon of obturator internus muscle
Which muscle is related to the greater sciatic notch
Piriformis… some structures pass above and others pass below it
What are the two types of fascia in this region
Superficial fascia – i.e. subcutaneous tissue
Deep fascia – in the thigh called fascia lata
What is the iliotibial tract
A lateral thickened area of the fascia lata
What fascia can be found in the popliteal fossa
popliteal fascia (deep fasia over popliteal fossa)
Outline the structure of the iliotibial tract
The fascia lata is a fibrous sheath that encircles the thigh like a subcutaneous stocking and tightly binds its muscles. On the lateral surface, it combines with the tendons of the gluteus maximus and tensor fasciae latae to form the iliotibial band
Where does the iliotibial tract go from/to
extends from the iliac crest to the lateral condyle of the tibia
What is the funtion of the tensor fasciae latae
- Flexion of the hip
- Abducts hip
- Medially rotates hip
- Stabilises hip (holds femoral head in acetabulum), especially during A/P tilting of pelvis when 1 leg supports all of the body weight
- Stabilises extended knee
Which muscle compartments are found in the region
Gluteal compartment
Anterior compartment of the thigh
Medial compartment of the thigh
Posterior compartment of the thigh
Which muscles are present in the gluteal region of the thigh
EXTENSORS, ABDUCTORS and EXTERNAL ROTATORS of the hip
State the two groups of muscles in the gluteal region and the names of the muscles in them
Gluteal muscles
- Gluteus maximus
- Gluteus medius
- Gluteus minimus
- (Tensor fasciae latae)
Short external (lateral) rotators of the hip
- Piriformis
- Obturator internus
- The gemelli (sup. and inf.)
- Quadratus femoris
Where do all of the short external rotators of the hip have their distal attachments
Piriformis… onto greater trochanter by round ligamnet
Obturator internus and the gemelli both onto the medial aspect of the greater trochanter by a common tendon
Quadrarus femoris on the quadrate tubercle on the intertrochanteric crest of teh femor
Where exactly does the iliotibial tract insert onto the tibia
Anterolateral (Gerdy) tubercle of tibia
Which is the largest muscle in the bodu
Gluteus maximus
What is the lateral intermuscular septum and where does it attach
fold of deep fascia in the thigh
Attaches to the iliotibial tract (laterally) and runs in a corona plane towards the lateral side of the femur
Outline the different parts of gluteus maximus
Superficial 3/4,,, which attaches to the iliotibial tract…
deep distal 1/4 which attaches to the gluteal tuberosity of the femur
What is the proximal attachment of gluteus maximus
Posterior gluteal line of ilium. dorsal surface of sacrum and coccyx and sacrotuberous ligament
What are the proximal and distal attachments of the gluteal muscles
On the diagam, from top to bottom its maximum, medius then minimus for origin
ORIGIN:
G. max from the posterior glteal line, dorsal sacrum and coccyx and sacrtuberous lig.
G med. from the external surface of ilium between anterior and posterior gluteal line
G min. external surface of iliu, between anterior and inferior gluteal line
(note that the glut. min is most deep, then medius then maximus)
EXTERNAL
max:iliotibial tract and some to the gluteal tuberosity of femur
med: greater trochanter of femur
min: greater trochanter of femur
What is the proximal attachment of piriformis, obturator intermus, gemelli and quadratus femoris
piriformis: anterior surface of 2nd-4th sacral segments adn sacrotuberous ligament
Obturator internus: pelvic aspect of obturator membrane and the bones surrounding obturator foramen
gamelli: superior, from ischial spine. inferior, from ischial tuberosity
Quad. femoris: from lateral border of ischial tuberosity
Which part of gluteus maximus attaches to the gluteal tuberosity
Inferior half of the deep part
Where does the sciatic nerve emerge
under piriformis
What are the names of the four bursas in this gluteal region
Bursa of obturator interns
Ischial bursa
Trochanteric bursa
Gluteofemoral bursa
Which muscle types are present in the anterioa compartment of the thigh
Hip Flexors and Knee Extensors
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Pectineus
Ilio-psoas
Tensor fasciae latae
Sartorius
Quadriceps femoris
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What are the names of the four quadriceps femoris muscles
Rectus femoris
Vastus medialis
Vastus intermedius
Vastus lateralis
Which is the longest muscle in the bod
The sartorius..
but it’s not particularlystrong
Which out of the quadriceps femoris muscles cross the hip and knee joint
The rectus femoris
… thus this aids ilio-psoas in hip flexion and also extends the leg at the knee via the patellar ligament
Which muscle in the anterior compartment of the thigh has an additional function to flexion of hip or extension of leg
Pectineus— adducts too
technically netters actually says this is a medial compartment muscle
What is odd about pectineus
It is part of the medial compartment, but innervated by teh femoral nerve, which is typical of anterior compartment muscles
T/f vastus medialis is the middle vastus muscle
F… it’s medial.
Behind the lateralis and medialis is the vastus intermedius
How are muscles from the anterior compartment of the thigh linked to the patella
Quadriceps femoris (the vastus muscles and rectus femoris) insert to the patella by the QUADRICEPS FEMORIS tendon.
Then to the tibia by the PATELLAR LIGAMENT
Differentiate the actions of the vastus muscles and rectus femoris
Rectus femoris attaches to ASIS and the ilium above the acetabulum,
whereas the vastus muscles originate from the femur.
SO RECTUS FEMORIS acts across knee and hip joint. Vastus just knee
Which is the most superifical muscle in the anterior compartment of teh thight
Sartorius
Where does sartorius attach
SUPERIOR portion of medial surface of the tibital shaft, anteror to insertions of semitendinosus and gracilis.
SO ON THE MEDIAL SHAFT OF TIBIA (posteriorly to anterior) it goes tendon of semitendinosus, gracilis, sartorius
Why is sartorius important
At it’s upper third, the MEDIAL border of sartorius forms the LATERAL border of teh femoral triangle
In the middle third, it forms the anterior wall of the adductor canal
General rules of thumb for nerves
ANTERIOR COMPARTMENT….
femoral nerve for all
bare in mind two come from abdomen
- Iliacus (also femoral)
- Psoas (anterior rami L1-L3)
MEDIAL COMPARTMENT:
obturator nerve
apart from
- pectineus (femoral)
- part of adductor magnus (sciatic)
POSTERIOR COMPARTMENT:
sciatic nerve (for all hamstrings)
What is articularis genu
Small muscles originating below vastus inermedius, pulls suprapatellar bursa away from patellar during extension
Where is the apex of the patella
The bottom
What muscles are present in the medial compartment of the thigh
Adductor longus Adductor brevis Adductor magnus Gracilis Obturator externus
Funvtion of medial compartment muscles
All adduct the thigh, apart from obturator externus which laterally rotates the thigh at the hip.
Adductor longus and magnus also medially rotate
What is the significantce of adductor lingus
Contributes floor of and its medial border is the medial border of femoral triangle
Outline from anterior to posterior the adductor muscles
Anterior first:
pectineus and adductus longus
adductus brevis
adductus magnus and obturator externus
What is the adductor hiatus
It is the gap between the ‘adductor part’ of the adductor magnus (laterally) and the ‘hamstring part’ (medially). The lateral part inserts onto the shaft of the femur whereas the medial part inserts onto the adductor tubercle.
A gap between these two insertions= adductor hiatus
Outline the innervatn of the adductor magnus
Lateral/adductor part= obturator
Medial/hamstring part= tibial division of sciatic nerve
Which muscle is supplied by the posterior branch of the obturator nerve
The obturator muscle
What is present in the posterior compartment of the thigh
Knee flexors and hip extensors
=THE HAMSTRINGS
What are the hamstrings
Semimembranosus
Semitendinosis and biceps femoris
What is the function of the hamstring muscles
Flex leg at the knee, extend the thigh at the hip. Rotate at the knee and the hip
T/F all the hamstrings cross both the knee and the hip
F… short head of biceps femoris does not cross the knee
Where does biceps femoris insert
Long and short head join to form a tendon which inserts onto the fibular head.
Extensions from this tendon blend with fibular collateral ligament
T/f the biceps femoris both flexes the knee and extends and laterally rotates the hip
T… but only the long head extends and laterally rotates the hip
(because the short head originates from the femur not the pelvis)
Function of semitendionsus
Flex knee, extend hip, medially rotate knee and hip (working w semimembranosus)
Outline the origina dn insertin of semitendinosus
Origin is with long head of biceps femoris at the ischial tuberosity
Insertion is on the medial condyle. The gracilis inserts anteriorly to this, and the sartorius anterior still
T/F the semimembranosus is superficial to the biceps femoris and the semitendinosus
F… it is deep to these structrus
Outline the boundaries of the femoral triangle
Superiorly – the inguinal ligament
Medially – adductor longus
Laterally - sartorius
What passes through the femoral triangle
Femoral nerve
Femoral artery
Femoral vein
Where does the lateral cutaneous nerve of the thigh come from
nerve of the lumbar plexus. It arises from the dorsal divisions of the second and third lumbar nerves (L2-L3)
What forms the roof and base of the femoral triangle
Anteriorly, the roof of the femoral triangle is formed by the fascia lata.
Posteriorly, the base of the femoral triangle is formed by the pectineus, iliopsoas and adductor longus muscles.
In which fasica is the femoral canal contained
Within the iliacus fascia
What is the saphenous opening
The saphenous vein, which runs superficially, enters the saphenous opening (an opening in the fascia lata, which overlies the femoral canal), to join the femoral vein
Differentiate the femoral canal, femoral sheath and fascia lata
Femoral canal is basically a division in the iliacus fascia through which femoral artery, vein and lymphatiucs pass.
The femoral sheath is a downward continuation of the iliacus fascia to continue surrounding the vessels (but it stops at the saphenous opening)
The fascia lata the ncovers over the iliacus fascia containing the femoral vessels.
Where does the femoral artery lie relative to the vein in the femoral canal
It lies lateral. The vein, artery and lympathics are deparated by septa.
What is the iliopectineal arch
thickened band of fused iliac fascia passing from the posterior aspect of the inguinal ligament anteriorly across the front of the femoral nerve to attach to the iliopubic eminence of the hip bone posteriorly
What forms the adductor canal
Vastus medialis (anteriorly) Adductor longus and adductor magnus (posteriorly) Sartorius (medially)
What is contained within the adductor canal
Femoral artery
Femoral vein
Saphenous nerve
Where is the femoral artery compared to the femoral vein in the adductor canal
Artery is medial to the vein
The nerve is anterior to bot these structures
Generally, what do the greater and lesser sciatic foramina contain
Greater sciatic foramen: structures passing from the pelvis to the thigh
Lesser sciatic foramen: structures passing from the pelvis to the perineum
State the course of the sciatic nerve
Passes from pelvis to buttock via greater sciatic notch/foramen
Where does the sciatic nerve lie in the buttock
In the buttock, lies in the inferior and medial quadrant
What are the divisions of the sciatic nerve
tibial nerve and the common peroneal nerve
What does the sciatic nerve supply
Supplies all the hamstring muscles and all the muscles below the level of the knee
Where should muscles into the buttock occur
use the superior and lateral quadrant
Which other nerve should be avoided in intramuscular injectiuon into the buttocks
superior gluteal nerves and vessels
Where does the superior gluteal nerve come from, and what is its course
dorsal divisions of the L4, L5 and S1. It leaves the pelvis through the greater sciatic foramen above the piriformis, accompanied by the superior gluteal artery and the superior gluteal vein
What is the Trendelenberg test
the abductors of the thigh prevent tilting of the pelvis when a limb is raised
if thigh tilts, then these abductors are paralysed
What type of joint is the hip joint
Synovial ball and socket joint
Head of the femur and the acetabulum
What is the name of the cartilage surrounding the acetabulum
ring of cartilage that surrounds the acetabulum of the hip= acetabular labrum
What are the boundaries pof the joint capsule of the hip joint
The capsule of the hip joint attaches to the edge of the acetabulum proximally. Distally, it attaches to the intertrochanteric line anteriorly and the femoral neck posteriorly.
T/F the joint capsiule extends further anteriorly than posteriorly
T
The ligament of the head of the femur is continuyous with which hstructure
Transverse acetabular ligament
Where does the ligament of the head of femur attach to the head of the femur
at the fovea
What are the three capsular ligament of the hip
Ilio-femoral ligament
Pubo-femoral ligament
Ischio-femoral ligament
What is the orbicular zone
……..
What us the blood supply to the head of the femur
The branches all come from the profunda femoris
Outline the blood vessels supplying the head of the femur
Deep profundus gives rise to medial and lateral circumflex femoral artery which wrap around the greater trochanter.
From the obturator artery comes the ACETABULAR BRANCH (i.e artery to head of femur) this lies WITHIN the ligament to the head of the femur
Why is the head of the femur more important in children?
……
What can fracture of the nek of the femur cause
fracture at the neck can lead to avascular necrosis of the head
Which muscles flex the hip
Ilio-psoas Sartorius Tensor fascia lata Rectus femoris Adductor longus Adductor brevis Adductor portion of adductor magnus gracilis
Which muscles adduct the hip
Adductor longus Adductor brevis Adductor magnus Gracilis Pectineus Obturator externus
Which msucles extend the hip
The hamstrings – semimembranosus, semitendinosus, biceps femoris
Posterior part of adductor magnus
Gluteus maximus
Which muscles abduct the hip
Gluteus medius
Gluteus minimus
Tensor fascia lata
Which musclkes externally rotate the hip
Obturator internus and obturator externus The Gemelli Piriformis Quadratus femoris Gluteus maximus
Which muscles internally rotate the hip
Anterior portion of gluteus medius
Anterior portion of gluteus minimus
Tensor fascia lata
Outline the arteries supplying this regin
External iliac artery
Femoral artery
Profunda femoris artery
Circumflex vessels
Femoral artery continues as superficial femoral artery ad then the popliteal artery
Where does the femoral artery lie
between the femoral vein (medial) and the femoral nerve (lateral)
Where does the femoral artery begin
midinguinal point
Where does the femoral artery travel around the knee medially
through the adductor hiatus
Where does the femoral artery continue to at the knee
After passing posteriorly through the adductor hiatus it runs as the popliteal artery between the medial and lateral condyles of the femur
What are the retinacular arteries
branches of the medial and lateral circumflex femoral arteries that extend to the head of the femur within the retinacular folds of synovial membrane surrounding the neck of the femur.
When are the femoral artery and vein then called the popliteal artery and vein
pass from the anterior compartment to the posterior of the knee (the popliteal fossa) through the hiatus of adductor magnus muscle
What are the superficial veins of the thigh
Long saphenous vein
Joins the femoral artery at the sapheno-femoral junction
Valve!
What are the deep veins of the thigh
Popliteal vein
Femoral vein
External iliac vein
Sapheno-femoral junction
Venae comitantes of the profunda femoris artery
Outline the lymphatic drainage of the thigh and buttock region
Lymph flows with the superficial and deep veins
Superficial inguinal lymph nodes
Deep inguinal lymph nodes
External iliac lymph nodes
Where are the deep lymph nodes located
Within the opening for the great saphenous vein
Where do exteranl iliac lymph nodes drain to
To common ilial lymph nodes then
To lateral lumbar (caval/aortic) lymph nodes and lubar lymphatic trunks
Where does teh femoral nerve pass
From the plexus, under the inguinal ligament
What does the sciatic nerve supply
Sciatic n. (or its terminal branches Tibial and Common Peroneal ns.) supply the remaining compartments (i.e. post. thigh, ant. and post. leg, foot)
Outline the motor segmental supply…
what spinal cord levels perform the following:
hip flexors
hip extensors
knee extensors
knee flexors
Hip Flexors L23 Hip Extensors L45 Knee Extensors L34 Knee Flexors L5S1
Outline the motor peripheral supply to the anterior thigh compartment
Femoral nerve.
Posterior divisions of lumbar plexus L234
Outline the motor peripheral supply to the medial thigh compartment
Obturator Nerve
Anterior divisions of the lumbar plexus (L234)
Outline the motor peripheral supply to the posterior thigh compartment
Sciatic nerve (L345S12)
Outline the motor peripheral supply to the gluteal compartment
Superior gluteal nerve (L45S1) – gluteus medius and minimus
Inferior gluteal nerve (L5S12) – gluteus maximus
Gluteus maximus is supplied by which nerve
inferior gluteal nerve
Outline the sensory segmental supply to:
Front of thigh
Back of thigh
Buttock
Dermatomal distribution
Front of the thigh : T12, L123
Back of the thigh : S123
Buttock S234
Outline the sensory peripjeral supply to the lower limb
Subcostal nerve (T12)
Ilio-hypogastric nerve (L1)
Ilio-inguinal nerve (L1)
Genito-femoral nerve (L12)
Lateral cutaneous nerve of the thigh (L23)
Sensory branches of the femoral nerve (L234)
Sensory branches of the obturator nerve (L234)
Posterior cutaneous nerve of the thigh (S23)
Saphenous nerve (L234)
Buttock nerves from the scaral plexus (L1-S3)
What is plantar flexion
(raising heel relative to toe… e.g. going on tip toes
What is dorsiflexion adn plantar flexion
Plantarflexion is true flexion
Dorsiflexion is true extension
What is the acetabular notch
The area at the bottom of the aetabulum which is without articular surface
What is the acetabular notch filled with
The trasnverse acetbaular ligament… this gives rise ot the ligament of the head of the femur
Note that the femral nerve has the posterior divisions from lumbo-sacral plexus even though it innervates anterior muscles (because the limb is pronated)
….
Which structures pass through the greater sciatic foramen, above and below piriformis?
(from self tests)
Above piriformis: Superior gluteal nerve, artery and vein.
Below piriformis: Inferior gluteal nerve, artery and vein, sciatic nerve, pudendal nerve.
