Hip, Buttock and Thigh Flashcards
What happens to the lower limbs during development?
twists (can be seen from segmentation of embryo and later in foetal development)
- structures below hips are rotated (everything anterior should have been posterior and vice versa) so moves associated with lower limbs and nervous supply are the wrong way round
What are the major regions of the lower limb?
gluteal region - considered part of the trunk
“free lower limb” - thigh, leg and foot
What is flexion and extension at the hip, knee and foot?
What other movements are possible?
hip - forward = flexion
knee - backwards = flexion
foot - Raising the toes = a true extension (DORSOFLEXION - the dorsum of the foot is being raised), lifting the heels/pointing the toes is a true flexion (PLANTARFLEXION )
- abduction and adduction at the hip, lateral and medial rotation of lower limbs
What are the bones of the hip?
3 parts fuse during development
- ilium (broad, flat blade)
- pubis (anterior region)
- ischium (posterior region)
Describe the structure of the femur
proximal end - very convex head (articular surface with acetabulum)
neck of femur is at an angle to long axis of shaft of the femur
two condyles at two ends which articulate plateau of tibia
Describe the weight bearing line of gravity of the femur
vertical, despite femur being at an angle (due to the articulation with the tibia being planar) -> weight transferred from the hip down vertically
What attaches from the sacral region to the iliac spine?
sacrospinal ligament
Where does the sacrotuberous ligament attach?
sacrum to tubercle
What do the sacrospinal and sacrotuberous ligament create?
two openings : greater and lesser sciatic foramina
What are the layers of fascia in the hip, buttock and thigh?
- superficial fascia - subcutaneous tissue
2. deep fascia (thick)
What is the fascia lata?
deep fascia in the thigh - extends like a stocking beneath the skin
binds anterior, posterior and medial thigh muscle groups
A lateral thickened area of the fascia lata is called the ilio-tibial tract
This lateral band runs down to the knee to bind the lateral muscles
What are the muscles in the gluteal region?
Gluteal muscles
- Gluteus maximus
- Gluteus medius
- Gluteus minimus
- (Tensor fasciae latae) – has more flexion activity
Short external (lateral) rotators of the hip
- Piriformis
- Obturator internus
- The gemelli (sup. and inf.)
- Quadratus femoris
What is gluteus maximus involved in?
- biggest muscle in body - has big, coarse fibres because it isn’t involved in subtle activity
- involved in extending the hip (backwards) and sitting down
- assists flexion of the knees during running, jumping, and other activities
Where does the gluteus maximus attach?
comes off small part of ilium and rest comes off sacrum and fascia of region
majority inserts and attaches to ilio-tibial tract (thickened lateral band)
partly attaches to gluteal tuberosity on posterior proximal shaft of femur
Where do the gluteal muscles attach?
all (except gluteaus maximus) attach to superior part of femur
What s the function of the gluteal muscles?
they’re lateral and medial rotators of hip
main job is to stabilise hip joint and pull head of femur into acetabulum
What is the tensor fascia lata?
Where does it attach?
Tensor fascia lata is related with the gluteus maximus in function and structure - assists in keeping the balance of the pelvis while standing, walking, or running
It comes off part of the anterior iliac crest, and it also inserts into the ilio-tibial tract (continuous)
- Due to its position, it is likely to have flexor activity on the trunk, as well as abduction
Describe the attachments of gluteus medius and gluteus minimus
relatively broad attachments - fibres converge and move laterally to attach to greater trochanter of femur
*involved in abduction of hip joint and steadying of pelvis
What is the piriformis?
one of the latral (external) rotators - sacrum to greater trochanter
What can you find in between the gemellus?
- superior and inferior gemellus
in between - obturator internus and quadratus femoris
What are the attachments of the obturator internus?
comes off obturator foramen (opening of front of pelvis)
has attachments at rim of obturator foramen
goes through 90-degree angle to intert at greater trochanter of proximal femur
What are the muscles in the anterior compartment of this region?
- Pectineus
- Ilio-psoas
- (Tensor fasciae latae)
- Sartorius
- Quadriceps femoris
> Rectus femoris
> Vastus medialis
> Vastus intermedius
> Vastus lateralis
Where does the pectineus attach?
What does it do?
comes off superior pubic ramus yo superior-anterior shaft of femur
- flexes and adducts
What are the attachements of the sartorius?
- long strap muscle coming off ASIS and crossing inferiorly and medially
crosses the knee joint and attaches below the knee joint - because it crosses the knee joint, it can be involved in acting on the joint
also crosses the hip joint, so is involved in flexing the hip and knee
What are the muscles in the anterior thigh?
- Flexors of the hip and extensors of the knee
- Psoas
- Iliacus
- Sartorius
- Tensor fascia lata (gluteal muscle, supplied by a gluteal nerve, but does have anterior function)
How many heads do the quadriceps have?
4
Rectus femoris
- fairly elongated, with a central, wider belly
- comes off the anterior inferior iliac spine, and down towards patella
On each side of the thigh are two of the vastae:
- vastus lateralis (lateral)
- vastus medialis (medial)
In between is the vastus medius
All of these converge either on to a tendinous structure on the patella, or DIRECTLY on to the patella
- Patella has formed within the ligament of quadriceps.
What is the patellar ligament?
distal portion of the common tendon of the quadriceps femoris, which is continued from the patella to the tibial tuberosity
It is a continuation of the quadriceps tendon.
- We can see ligamentum patellae passing inferiorly to the tibial tuberosity.
Which muscles would you find in the medial compartment of the thigh?
hip adductors
- Adductor longus (long)
- Adductor brevis (short)
- Adductor magnus (big)
- Gracilis
- Obturator externus
What are the attachments of the adductor longus, brevis and magnus?
There are distal attachments on the posterior of the femoral shaft (in particular, a ridge that runs down the femur – the linea aspera) - Adductor longus, brevis and magnus all have this attachment
What can cause a groin strain?
Groin strain: injury to any of the adductor muscles of the thigh, on the inner side of the thigh
An acute groin strain is usually caused by sudden movements:
- kicking
- twisting to change direction while running, or jumping
- The adductor muscles act to adduct the thigh and are involved in groin strains
What are the attachments of the gracialis muscle?
- Gracilis muscle attaches from the inferior pubic ramus - crosses the knee joint and inserts into the proximal medial surface of the body of tibia
- It is a long strap muscle, that stays medial
Where would you find the obturator externus?
What does it do?
The obturator foramen is the circle formed by the ischium and the pubis - Obturator externus is contained within the external rim of the foramen
Obturator externus acts as the lateral rotator of the hip joint - It stabilizes the hip joint as a postural muscle
What is the adductor hiatus?
There is a gap in the attachment of adductor magnus
What are the muscles in the posterior compartment of the thigh?
Knee flexors and hip extensors - “The Hamstrings”
- Semimembranosus
- Semitendinosus
- Biceps femoris
Where do all the posterior muscle compartments have attachments to?
ischial tuberosity
What are the attachments of the biceps femoris?
long head travels laterally to insert into the head of the fibula
short head comes off the posterior surface of the femoral shaft.
- long head crosses the hip joint, but the short one doesn’t
Together, the two heads form a tendon, which attaches to the head of the fibula, and so obviously crosses the knee joint
Where do the semitendinosus and semimembranosus attach?
Semitendinosus: rope like Semimembranosus: flatter
Both come off the ischial tuberosity and travel towards the lateral side
What is the pes anserinus?
(“goose foot”) refers to the conjoined tendons of three muscles that insert onto the anteromedial surface of the proximal extremity of the tibia. The muscles are the sartorius, gracilis and semitendinosus
What are the borders of the femoral triangle?
Superiorly – the inguinal ligament
Medially – adductor longus
Laterally – sartorius
What can you find in the femoral triangle?
Femoral nerve
Femoral artery
Femoral vein
lymph nodes
- The femoral triangle is covered by fascia lata. There is an opening in the fascia lata called the saphenous opening. This is because the great (long) saphenous vein enters the triangle to JOIN the femoral vein running within it.
What form the adductor canal (Hunter’s canal)?
What is contained in it?
- Vastus medialis (anteriorly)
- Adductor longus and adductor magnus (posteriorly)
- Sartorius (medially)
- Extends along the medial aspect of the thigh
Contains:
- Femoral artery
- Femoral vein
- Saphenous nerve (terminal branch of the femoral nerve – it goes the furthest in the lower limb)
Where do the greater and lesser sciatic foramen pass through?
Greater sciatic foramen: structures passing from pelvis -> thigh
Lesser sciatic foramen: structures passing from pelvis -> perineum
Where does the sciatic nerve pass through?
What does it supply?
Passes from pelvis to buttock via greater sciatic notch/foramen (along posterior aspect of the thigh)
In the buttock, it lies in the inferior and medial quadrant
*The sciatic nerve normally enters the gluteal region inferiorly to piriformis muscle, but can be superior or pierce the muscle itself. There are variations of the emergence of the sciatic nerve from the pelvis interior to the gluteal region
Supplies all the hamstring muscles and all the muscles below the level of the knee
What does the sciatic nerve consist of?
- tibial nerve
- the common peroneal nerve (inconstant level)
What is the safe are?
a triangle between the tubercle of the iliac crest and ASIS
safe triangle overlies gluteus medius
avoid gluteus maximus in a buttock intramuscular injection
How can you evaluate motor loss of hip abductors?
The abductors of the thigh prevent tilting of the pelvis when a limb is raised
When you raise a foot off the ground during walking or running, the contralateral medius and minimus contract to keep the hip steady
* If they are paralysed, you get a tilt
The Trendelenberg test is done to evaluate the motor loss of the abductors (gluteus medius and minimus) of the hip joint. Patients with a positive Trendelenberg test tend to “waddle” when they walk
First, the subject is asked to stand on both legs. Both right and left side of the pelvis should remain at same level without any tilt. Examiner should stand behind the subject and feel the pelvis. Then ask the subject to raise one leg off the ground. The pelvis should remain horizontal on one leg
If the pelvis on the raised leg side drops downward then the Trendelenberg test is said to be positive
A positive test indicates a loss or weakness of the motor function of the abductor muscles (gluteus medius and minimus) in the leg the subject is standing on (supported side)
What kind of joint is the hip joint?
Synovial ball and socket joint formed by the head of the femur and the acetabulum
- It is deepened in life with an acetabular labrum
What are the features of the capsule of the hip joint?
- Extends further anteriorly than posteriorly
- Within capsule runs the blood supply of the femur head
- Hip fractures are classified intracapsular and extracapsular
Where does the ligament of the head of the femur attach?
comes off transverse acetabular ligament yo recess at back (filled with fibro-fatty material). This is the acetabular fossa.
What are the ligaments of the hip joint?
- Ilio-femoral ligament
- Pubo-femoral ligament
- Ischio-femoral ligament
- The ligament of the head of the femur
- All the ligaments come at different angles. They are arranged spirally, such that when the hip is extended, they shorten and pull the head of the femur into the acetabulum
What can a break in the femur cause?
- most of the blood supply to head of femur comes from medial and lateral circumflex arteries
damage to artery of the head of the femur via intrascapular fracture of femoral neck (much more important in children than in adults) -> avascular necrosis of the femoral head
What are the arteries of this region?
- External iliac artery
- Femoral artery – midinguinal point
- Femoral artery lies between the femoral vein (medial) and the femoral nerve (lateral)
- Profunda femoris artery
- Circumflex vessels
- Femoral artery continues as the superficial femoral artery and subsequently as the popliteal artery
Describe the positions of the arteries
The abdominal aorta divides -> common iliac arteries -> further divide into the external and internal iliac arteries
The external iliac artery passes under the inguinal ligament, and changes its name to the femoral artery
The internal iliac artery gives the obturator artery that is involved in supplying some of the medial structures.#
Much of the supply is from the femoral artery, which gives off a big branch in the thigh (the profunda femoris).
The femoral artery passes through the femoral triangle and subsartorial canal, and through the adductor hiatus.
After the adductor hiatus, femoral artery -> popliteal artery.
The femoral artery and vein pass from the anterior compartment to the posterior of the knee (the popliteal fossa) through the hiatus of adductor magnus muscle. After passing posteriorly, they are named the popliteal artery and vein.
What are the veins in this region?
Superficial veins
- Long saphenous vein (joins the femoral vein at the sapheno-femoral junction)
Deep veins
- Popliteal vein
- Femoral vein
- External iliac vein
- Sapheno-femoral junction
- Venae comitantes of the profunda femoris artery
What are the lymph nodes in this region?
What is the clinical significance of these nodes?
- Lymph flows with the superficial and deep veins
- Superficial inguinal lymph nodes
- Deep inguinal lymph nodes
- External iliac lymph nodes
- There are also nodes at the knee region (popliteal nodes)
*they can drain nodes in the groin and pelvic region - can be important in pelvic disease
Where do the nerves of the lower limb emerge from?
emerge from the Lumbosacral Plexus
- Femoral nerve supplies anterior thigh
- Obturator nerve supplies medial (adductor) thigh
- Sciatic nerve (or its terminal branches Tibial and Common Peroneal nerves) supply the remaining compartments (i.e. posterior thigh, anterior and posterior leg, foot)
- The lumbosacral plexus is the lower limb equivalent of the brachial plexus. Because everything gets twisted around, although the femoral nerve is anterior, it is actually from the posterior divisions
Describe the motor segmental and peripheral supply ofthe lower limbs
Motor segmental supply
- Hip Flexors: L2, L3
- Hip Extensors: L4, L5
- Knee Extensors: L3, L4
- Knee Flexors: L5, S1
Motor peripheral supply
- Anterior Thigh: Femoral Nerve, Posterior divisions of lumbar plexus (L234)
- Medial Thigh: Obturator Nerve, Anterior divisions of the lumbar plexus (L234)
- Posterior Thigh: Sciatic nerve (L345S12)
- Gluteal Compartment:
> Superior gluteal nerve (L4, L5, S1) – gluteus medius and minimus
> Inferior gluteal nerve (L5, S1, S2) – gluteus maximus
Describe the sensory segmental and peripheral supply of the lower limbs
Sensory segmental supply - dermatomal distribution
- Front of the thigh: T12, L1, L2, L3
- Back of the thigh: S1, S2, S3
- Buttock S2, S3, S4
*In general, L3 to the knee, L4 to the floor.
Sensory peripheral supply
- Subcostal nerve (T12)
- Ilio-hypogastric nerve (L1)
- Ilio-inguinal nerve (L1)
- Genito-femoral nerve (L1, L2)
- Lateral cutaneous nerve of the thigh (L2, L3)
- Sensory branches of the femoral nerve (L2, L3, L4)
- Sensory branches of the obturator nerve (L2, L3, L4)
- Posterior cutaneous nerve of the thigh (S2, S3) – biggest peripheral nerve
- Saphenous nerve (L2, L3, L4)
- Buttock nerves from the sacral plexus (L1-S3)
