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Year 2 Anatomy of the Limbs > Hip, buttock and thigh > Flashcards

Hip, buttock and thigh Flashcards

1
Q

What happens to development of the lower limbs in-utero?

A

There is twisting of the lower limb during development. There is permanent PRONATION at the mid-thigh level, which makes terminology of the lower limb confusing – everything from the mid-thigh is back-to-front.

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2
Q

What are the two major regions of the lower limb?

A

GLUTEAL region (part of the trunk), and the FREE LOWER LIMB (thigh, leg and foot).

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3
Q

What does the ‘leg’ mean anatomically?

A

Between the knee and the ankle. The bit above the ankle is called the thigh.

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4
Q

What are the bones of the region?

A

The pelvis (hip bone), the femur and patella.

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5
Q

What is the anatomy of the pelvis?

A

 Made up of ILIUM, ISCHIUM and PUBIS.

 Acetabulum is where the femur articulates, though the acetabular fossa is not involved in the articulation.

 Ala of ilium (posterior) and iliac fossa (anterior).

 Pubis has a body, crest, tubercle, superior and inferior rami.

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6
Q

Which parts of the pelvic bone are in development in a child?

A

See photo for regions with epiphyseal plates.

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7
Q

What is the anatomy of the femur?

A

 PROXIMALLY: head of the femur, greater and lesser trochanters, and intertrochanteric line and crest.

 Greater trochanter is a quadrilateral prominence, for the insertion of various tendons; the lesser trochanter is a cone-like prominence and is an attachment for various tendons.

 Intertrochanteric line is on anterior aspect, roughly following the shaft of the femur. It marks the transition between the femoral neck and shaft. The intertrochanteric crest is a bony ridge posteriorly, also separating the femoral neck and shaft.

 Femoral head has a FOVEA (depression), allowing attachment to the hip joint by a ligament.

 SHAFT: anterior surface is smooth; posterior surface has many lines. The linea aspera – with a medial and lateral ridge – is the site of many muscle attachments. Proximally, the medial ridge becomes the pectineal line, while the lateral ridge becomes the gluteal tuberosity.

 DISTALLY: lateral and medial condyle (articulate with the tibia), intercondylar fossa and lateral and medial epicondyles. Adductor tubercle is a bony protuberance above the medial epicondyle.

 The trochlea of femur is the cartilaginous part of the distal femur for articulation with the patella.

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8
Q

What type of bone is the patella?

A

The patella is a sesamoid bone – formed within a tendon of a muscle.

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9
Q

What is the clinical significance of the intertrochanteric line?

A

This area is prone to fractures from the stress it is subject to from the weight of the trunk.

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10
Q

Where are femur fractures most common? (x2)

A

Fracture of the femoral neck – most common, and intertrochanteric line.

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11
Q

What does the anteversion of the femoral neck describe? Alternative name?

A

aka TORSION ANGLE. It is the angular difference between the axis of femoral neck and the transcondylar axis of the knee.

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12
Q

What is the typical anteversion in adults and from birth?

A

In the adults it is around 12 degrees. At birth, it is around 30- 40 degrees which reduces by a degree each year until 20+.

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13
Q

What is the result of an abnormally high anteversion angle?

A

A higher anteversion angle results in intoed feet (feet turned towards the midline). In-toeing is normal in young children.

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14
Q

What are the important components of the ligamentous anatomy of the pelvis, relevant to the lower limb? Why are they important?

A

• Important ones are those relating to the sacrum and ischium.

  • SACRO-TUBEROUS LIGAMENT: from the sacrum to the ischial tuberosity.
  • SACROSPINOUS LIGAMENT: from the sacrum to the ischial spine.
  • Important because: They turn the greater and lesser sciatic notch into the GREATER and LESSER SCIATIC FORAMEN, where structures pass between the posterior buttock and the interior of the pelvis.
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15
Q

What is the fascia of the region?

A

There are two layers – superficial and deep fascia. Superficial fascia denotes the fascia of the subcutaneous tissue. The FASCIA LATA is a component of deep fascia that surrounds the thigh – like a stocking. Laterally, there is a thickened area of the fascia lata called the ILIO-TIBIAL TRACT. The fascia lata merges with fibres and fascia at the buttock and knee.

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16
Q

What are the movements of the lower limb? (x10) !!!

A

Look at photo.

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17
Q

What are the compartments of the region? (x4)

A

• Gluteal compartment. • Anterior compartment of the thigh. • Medial compartment of the thigh. • Posterior compartment of the thigh.

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18
Q

What type of muscles are contained within each compartment of the region? !!!

A

• GLUTEAL REGION: Extensors, abductors and external rotators of the hip. • ANTERIOR COMPARTMENT OF THE THIGH: hip flexors and knee extensors. • MEDIAL COMPARTMENT OF THE THIGH: hip adductors. • POSTERIOR COMPARTMENT OF THE THIGH: the hamstrings – knee flexors and hip extensors.

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19
Q

What are the muscles of the gluteal compartment? (x8)

A

• GLUTEAL MUSCLES: • Gluteus maximus. • Gluteus medius. • Gluteus minimus. • Tensor fasciae latae. • SHORT EXTERNAL (LATERAL) ROTATORS OF THE HIP: • Piriformis. • Obturator internus. • The gemelli (superior and inferior). • Quadratus femoris.

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20
Q

What are the attachments of the gluteus maximus? Functions? (x3)

A
  • PROXIMALLY: fascia covering gluteus medius, ilium, fascia of erector spinae, and dorsal surface of lower sacrum.
  • DISTALLY: 75% fibres merge with the fascia lata in the ilio-tibial tract; 25% attach to the greater tuberosity of the femur.
  • FUNCTION: Extensor of the hip joint, abduction and lateral rotation.
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21
Q

What are the attachments of the gluteus medius? Functions? (x2)

A
  • PROXIMAL: ilium.
  • DISTAL: lateral surface of the greater trochanter, then passes laterally over the hip joint.
  • FUNCTION: Abducts femur and medially rotates the thigh.
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22
Q

What are the attachments of the gluteus minimus? Functions? (x2)

A
  • PROXIMAL: ilium.
  • DISTAL: anterolateral surface of the greater trochanter.
  • FUNCTION: abducts femur and medially rotates the thigh.
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23
Q

What are the attachments of the tensor fascia lata? Functions?

A
  • PROXIMAL: crest of ilium.
  • DISTAL: iliotibial tract of fascia lata.
  • FUNCTION: stabilises the knee in extension.
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24
Q

What are the attachments of the Piriformis? Functions? (x2)

A
  • PROXIMAL: anterior sacrum.
  • DISTAL: greater trochanter.
  • FUNCTION: laterally rotates an extended femur and abducts a flexed femur.
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25
Q

What are the attachments of the Obturator internus? Functions? (x2)

A
  • PROXIMAL: deep surface obturator membrane.
  • DISTAL: greater trochanter.
  • FUNCTION: laterally rotates an extended femur and abducts a flexed femur.
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26
Q

What are the attachments of the gemelli (superior and inferior)? Functions? (x2)

A
  • PROXIMAL: superior – ischial spine; inferior – ischial tuberosity.
  • DISTAL: greater trochanter.
  • FUNCTION: laterally rotates an extended femur and abducts a flexed femur.
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27
Q

What are the attachments of the quadratus femoris? Functions?

A
  • PROXIMAL: lateral ischium.
  • DISTAL: intertrochanteric crest.
  • FUNCTION: laterally rotates.
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28
Q

What are the muscles of the anterior compartment of the thigh? (x5)

A

• Pectineus. • Ilio-psoas. • Tensor fascia latae. • Sartorius. • Quadriceps femoris.

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29
Q

What are the four heads of the quadriceps femoris?

A

Rectus femoris, vastus medialis, vastus intermedius, vastus lateralis.

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30
Q

What are the attachments of the pectineus? Functions? (x2)

A
  • PROXIMAL: pectineal line of pubic bone.
  • DISTAL: pectineal line of the femur (medially)
  • FUNCTION: flexion and adduction.
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31
Q

What are the attachments of the ilio-psoas? Functions?

A
  • PROXIMAL: Psoas major (from the lumbar spine) and iliacus (from the iliac fossa) merges to form the ilio-psoas muscle. Passes under the inguinal ligament.
  • DISTAL: lesser trochanter of the femur.
  • FUNCTION: flexion of the hip.
32
Q

What are the attachments of the sartorius? Functions? (x4)

A
  • PROXIMAL: anterior superior iliac spine. Course is inferior-medial.
  • DISTAL: medial surface of proximal tibia.
  • FUNCTION: flexion of knee, flexion, abduction and lateral rotation of the hip.
33
Q

What are the proximal attachments of the rectus femoris? Functions? (x2)

A
  • PROXIMAL: straight head – AIIS, reflected head – ilium.
  • FUNCTION: thigh flexor and knee extensor.
34
Q

What are the proximal attachments of the vastus medialis? Functions?

A
  • PROXIMAL: intertrochanteric line, pectineal line and medial lip of linea aspera.
  • FUNCTION: Knee extensor.
35
Q

What are the proximal attachments of the vastus intermedius? Functions?

A
  • PROXIMAL: upper two-thirds of anterior and lateral surfaces of the femur.
  • FUNCTION: Knee extensor.
36
Q

What are the proximal attachments of the vastus lateralis? Functions?

A
  • PROXIMAL: intertrochanteric line, greater trochanter, gluteal tuberosity and lateral lip of the linea aspera.
  • FUNCTION: knee extensor.
37
Q

What is the distal attachment of the Quadriceps femoris?

A

QUADRICEPS FEMORIS TENDON: muscles all converge to form a tendon, which the patella is embedded in. This tendon continues to the tibial tuberosity – projection just posterior of the knee that’s easily palpable.

38
Q

What are the muscles of the medial compartment of the thigh? (x5)

A

• Adductor longus. • Adductor brevis. • Adductor magnus. • Gracilis. • Obturator externus.

39
Q

What are the attachments of the Gracilis? Functions? (x2)

A
  • PROXIMAL: body of pubis and pubic/ischial rami.
  • DISTAL: medial surface of proximal shaft of tibia.
  • FUNCTION: Adducts thigh and flexes knee.
40
Q

What are the attachments of the Adductor longus? Functions? (x2)

A
  • PROXIMAL: body of pubis.
  • DISTAL: linea aspera on middle one-third of shaft of femur.
  • FUNCTION: adducts and medially rotates the thigh.
41
Q

What are the attachments of the Adductor brevis? Functions? (x2)

A
  • PROXIMAL: body of pubis and inferior pubic ramus.
  • DISTAL: posterior surface of femur and upper one-third of linea aspera.
  • FUNCTION: adducts and medially rotates the thigh.
42
Q

What are the attachments of the Obturator externus? Functions? (x2)

A
  • PROXIMAL: external surface of obturator membrane.
  • DISTAL: trochanteric fossa.
  • FUNCTION: adducts and laterally rotates the thigh.
43
Q

What is the anatomy and attachments of the Adductor magnus? Functions? (x2)

A
  • Split into two parts: ADDUCTOR and HAMSTRING part.
  • ADDUCTOR PART: attached proximally to ischiopubic ramus, and distally to the proximal femur, linea aspera and medial supracondylar line. Between its attachment to the linea aspera and supracondylar ridge, there is no attachment – this leaves the ADDUCTOR HIATUS, where femoral vessels pass from anterior to posterior thigh.
  • HAMSTRING PART: attached proximally to ischial tuberosity, and distally to the adductor tubercle and supracondylar line.
  • FUNCTION: adducts and medially rotates the thigh.
44
Q

What are the muscles of the posterior compartment of the thigh? (x3)

A

• Semimembranosus. • Semitendinosus. • Biceps femoris.

45
Q

What are the attachments of the Semimembranosus? Functions? (x4)

A
  • PROXIMAL: ischial tuberosity.
  • DISTAL: medial tibial condyle.
  • FUNCTION: extends and medially rotates thigh, flexes and medially rotates knee.
46
Q

What are the attachments of the Semitendinosus? Functions? (x4)

A
  • PROXIMAL: ischial tuberosity.
  • DISTAL: medial surface of proximal tibia.
  • FUNCTION: extends and medially rotates thigh, flexes and medially rotates knee.
47
Q

What are the attachments of the Biceps femoris? Functions? (x4)

A
  • PROXIMAL: LONG HEAD attaches to ischial tuberosity; SHORT HEAD attaches to lateral lip of linea aspera.
  • DISTAL: head of fibula.
  • FUNCTION: extends and medially rotates thigh, flexes and medially rotates knee.
48
Q

What are the borders of the femoral triangle?

A

SUPERIORLY: the inguinal ligament; MEDIALLY: the adductor longus; LATERALLY: sartorius.

49
Q

What is contained within the femoral triangle? Arrangement within canal.

A

Femoral nerve, femoral artery and femoral vein. Femoral sheath encloses the femoral artery and vein, but not the nerve – a portion of it forms the femoral canal medially. They are covered in deep fascia and arranged as NAVY – nerve, artery, vein, yup (from lateral to medial arrangement).

50
Q

What is the Adductor Canal? Boundaries? Contents?

A

Also known as Hunter’s Canal and Sub-sartorial Canal: extends along medial aspect of the thigh and formed by VASTUS MEDIALIS (anteriorly), ADDUCTOR LONGUS and ADDUCTOR MAGNUS (posteriorly) and SARTORIUS (medially). Contains: femoral artery, femoral vein and saphenous nerve (branch of the femoral nerve).

51
Q

What is the function of the greater sciatic foramen and lesser sciatic foramen?

A

GREATER: structures pass from the pelvis into the thigh; LESSER: structures pass from the pelvis into the perineum.

52
Q

What is the course of the sciatic nerve? What does it supply?

A
  • Passes from pelvis to the inferior-medial part of the buttock via the greater sciatic foramen.
  • It enters inferiorly to the piriformis, but can also be superior or pierce the muscle itself.
  • It passes along the posterior aspect of the thigh and divides into the TIBIAL NERVE and COMMON PERONEAL NERVE.
  • Supplies the hamstring muscles and all the muscles below the level of the knee.
53
Q

What is the clinical significance that the sciatic nerve may pierce the piriformis muscle?

A

In these patients, intramuscular injections may damage this nerve. To avoid this risk, you inject into a safe area of the buttock – the superior and lateral quadrant. This is done by laying the hand over the lateral region of the buttock and injecting between the index and middle finger.

54
Q

How is hip abduction tested?

A

When you lift one foot, the abductors restore balance of the trunk by preventing tilting of the pelvis. The TRENDELENBERG TEST utilises this.

55
Q

What is the anatomy of the hip joint?

A
  • Synovial ball and socket joint.
  • Articulation between the head of the femur and the acetabulum – all the pelvic bones make up the acetabulum.
  • Acetabulum contains the acetabular fossa which does not articulate with the femur.
  • Articular cartilage covers the head of the femur. The head also contains a FOVEA – a depression which attaches the ligament of the head of the femur.
  • Acetabulum labrum is an incomplete ring of cartilage which deepens the acetabulum socket. It’s continuous with the transverse acetabular ligament, which attaches the ligament of the head of the femur with the femur head.
56
Q

What are the ligaments of the hip joint - attachments? (x4) Nomenclature? Overall arrangement and function of this arrangement?

A
  • Named in relation to the pelvic bone to which they attach proximally.
  • Ilio-femoral ligament – attached to the ilium between ASIS and acetabulum, and laterally to the intertrochanteric line.
  • Pubo-femoral ligament – attached to ilio-pubic eminence and obturator membrane, and laterally to the iliofemoral ligament.
  • Ischio-femoral ligament – attached to ischium and greater trochanter of femur.
  • The ligament of the head of the femur – attaches head of femur to the TRANSVERSE ACETEBULAR LIGAMENT (ligament will transverses across the lower portion of the acetabulum).
  • OVERALL: arranged spirally so that when the hip is extended, they pull the head towards the pelvis, thereby stabilising the joint.
57
Q

What is the arterial blood supply of the region?

A
  • The abdominal aorta produces common iliac arteries which divide to the external and internal iliac arteries.
  • EXTERNAL ILIAC ARTERIES divide to form the femoral and profunda femoris arteries.
  • PROFUNDA FEMORIS produces the medial and lateral circumflex arteries to form the ARTERIAL RING around the neck to supply the femur head. It also produces perforating arteries to supply the shaft.
  • FEMORAL ARTERY passes through anterior compartment as the superficial femoral artery to posterior knee though hiatus of adductor magnus muscle, where it becomes popliteal artery.
58
Q

What is the surface anatomy of the femoral artery?

A

Artery lies at the level of the inguinal ligament at the mid-inguinal point.

59
Q

What is the arterial blood supply of the head of the femur?

A

Medial and lateral circumflex femoral arteries (branches of the profunda femoris artery), and acetabular branch of obturator artery.

60
Q

What is the clinical significance of the blood supply of the head of the femur? Note about intertrochanteric fractures?

A

The circumflex arteries become damaged in intracapsular fractures (within joint capsule), and fracture of the neck of the femur (- the circumflex artery is particularly important in children). This can lead to AVASCULAR NECROSIS of the femoral head. INTERTROCHANTERIC FRACTURES: run from greater to lesser trochanter, and does not involve the neck, so preserves femoral head blood supply and does not lead to necrosis.

61
Q

What is the venous drainage of the region?

A
  • Superficial drainage by the LONG (or GREAT) SAPHENOUS VEIN. It passes up the medial aspect of the leg and thigh, piercing the fascia of the thigh to join the deep system at the femoral triangle. Here, it joins the DEEP FEMORAL VEIN at the sapheno-femoral junction.
  • Deep drainage starts with the SMALL SAPHENOUS VEIN which joins tibial veins to form the POPLITEAL VEIN – runs along popliteal and femoral arteries. This, and the venae comitantes of the profunda femoris artery, join the femoral vein.
  • Femoral vein ascends to the external iliac vein –> common iliac vein –> IVC.
62
Q

Where is the femoral vein in relation to the surface anatomy of the femoral artery?

A

Femoral vein is MEDIAL.

63
Q

Importance of valves in the venous drainage of the region?

A

There is an important valve at the sapheno-femoral junction that prevents blood passing from the deep to the superficial system (between long saphenous vein and deep femoral vein). This valve is often faulty or incompetent in varicose veins.

64
Q

What is the lymphatic drainage of the region? (x4 node clusters)

A
  • 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.
  • There are also popliteal lymph nodes associated with popliteal vein.
65
Q

What is the motor peripheral supply of the compartments of the lower limb? (x4)

A

• Superior and inferior gluteal nerve supply the tensor fascia lata, gluteus medius and minimus, and gluteus maximus respectively in the gluteal compartment of the thigh. • Femoral nerve supplies anterior compartment of thigh. • Obturator nerve supplies the medial compartment of thigh. • Sciatic nerve supplies the remaining compartments (posterior thigh, leg and foot).

66
Q

What are the lumbar divisions of the motor peripheral nerves of the lower limb? (x5) !!!

A

• SUPERIOR GLUTEAL NERVE – L45 S1. • INFERIOR GLUTEAL NERVE – L5 S12. • FEMORAL NERVE – L234. • OBTURATOR NERVE – L234. • SCIATIC NERVE – L345S12.

67
Q

What is the motor segmental supply of the region? (x4)

A

• Hip flexors – L23. • Hip extensors – L45. • Knee extensors – L34. • Knee flexors – L5, S1.

68
Q

What is the sensory segmental supply of the region?

A
  • Front of thigh – T12, L123.
  • Back of thigh – S123.
  • Buttock – S234.
  • Remember, L3 to the knee and L4 to the floor.
  • These dermatomes are different – people disagree: one is theoretical; the other is based on segmental supply.
69
Q

What is the sensory peripheral supply of the region? (Do I need to know this?)

A
  • 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)
70
Q

What is the gluteal fold? Surface anatomy?

A

The inferior border of the gluteus maximus – extend the thigh at hip joint and feel the muscle contracting and producing the rounded contour of the buttock.

71
Q

What is the gluteal sulcus? Relationship to fold?

A

The visible skin crease separating the buttock and thigh which crosses the true gluteal fold obliquely.

72
Q

How do you test for gluteus maximus?

A

Subject lies prone with the knee flexed. Ask the subject to extend the thigh at the hip joint while applying resistance at the distal end of thigh. Examiner palpates the rounded contour of the buttock for the muscle contraction – INFERIOR GLUTEAL NERVE, L5S12.

73
Q

How do you test for the gluteus medius and minimus?

A

Subject lies on the side with the lower limb fully extended. Ask the subject to abduct the limb at the hip joint while applying resistance at the distal end of thigh. Examiner palpates the contraction of the gluteus medius just inferior to iliac crest – SUPERIOR GLUTEAL NERVE, L5S1.

74
Q

How do you test for the tensor fascia lata?

A

Same as for gluteus medius but this time the subject is rolled slightly toward supine (not fully) and examiner’s fingertip on the Tensor fascia lata muscle and the ilio-tibial band (which may become visible) - SUPERIOR GLUTEAL NERVE, L5S1.

75
Q

How do you test for the hamstrings? (Biceps femoris, semitendinosus and semimembranosus.)

A

Subject lies prone with the knee flexed to 30 degrees. The examiner applies an opposing force just above the posterior side of the ankle while the subject attempts to flex the knee further. The hamstring tendons will be seen around the popliteal region and the muscle contraction is palpable on the posterior side of the mid-thigh.

76
Q

How do you test for the quadriceps?

A

Subject sits on the couch with knees bent to 90 degrees over the edge. The examiner applies pressure at the distal part of the leg while the subject attempts to extend it. The contracting quadriceps can be palpated on the anterior thigh.

77
Q

What is the Trendelenburg Test?

A

• Tests for integrity of the abductors of the hip joint. • 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). The subject would tend to ‘waddle’ when they walk.

Year 2 Anatomy of the Limbs (8 decks)

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