Lecture 9 Flashcards
What is the gluteal sulcus/fold?
A combination of the Gluteus Maximus muscles
What is the relative position of the Gluteal region and the pelvis?
Gluteal region = Posterior to pelvis
What is the Gluteal region bound Superiorly and inferiorly to?
Gluteal region is bound:
- Superiorly: to Illiac crests
- Inferiorly: to Gluteal Sulcus/Fold (created by the gluteus maximum muscles)
What is another name for the gluteal sulcus?
gluteal fold
creation of the gluteus maximus muscles
What are the 3x components of the hip bones from largest to smallest?
Illium + Ischium + Pubis
What is the largest and smallest component of the hip bones?
Largest: Illium
Ischium
Smallest: Pubis
What is the most lateral part of the hiip bones?
Illiac crest
- hip bones
- poking laterally
What is the most Posterior part of the Ischium?
Ischial spine
pokes posteriorly
Gluteus Maximus
Largest mucle in body
Very very powerful
Hip extensor (standing up from sitting, walking up stairs)
Origin: Upper portion of illium, Posterior Sacrum, Coccyx, sacrotuberous Ligament (attached across sacrum and illium proximally)
Insertion: ITB, gluteal tuberosity of femur (lateral aspect of femur, alongside tensor facia lata and into ITband-thick band of fascia i lateral thigh)
Action: Extends and laterally rotates the thigh
Nerve Supply: Inferior gluteal Nerve
Gluteus Medius
Deep to Gluteus Maximus
Origin: Illium between posterior and middle gluteal lines (illiac crest)
Insertion: Greater trochanter (proximal femur onto greater tuberosity)
Action: Abducts and internally rotates thigh, steadies pelvis
Primary ABDuctor of the hip - upon contraction femur moves out Laterally
-really important for holding your Pelvis Level when you Walk
- Problem: Lurching Gate. v. distinctive. hip problems/surgery. Lean to one side as you walk, as other/only one leg takes all the weight (pelvis isnt being held level by the abducting gluteus medius/ not moving femur out laterally)
Nerve Supply: Superior Gluteal
Gluteus Minimus
Origin: illium between middle and inferior gluteal lines
Insertion: Greater tichanter
Action: Abducts and internally rotates thigh
Nerve Supply: Superior Gluteal
Piriformis
“little pear”
comes through Sciatic notch -> into sacrum
Origin: Anterior Sacrum, sacrotuberous Ligament
Insertion: Greater trochanter
Action: Externally rotates thigh
Nerve Supply: Sacral Plexus
Obturator Internus
Origin: Obturator Foreamen and membrane
Insertion: Greater trochanter
Action: Externally rotates the thigh
Nerve Supply: Nerve to OI (sacral plexus)
Superior and Inferior Gemelli
Origin:Ischial spine (s) and ischial tuberosity (i)
Insertion: Greater trochanter
Action: Externally rotates thigh
Nerve Supply: Nerve to OI (s). Nerve to QF (i)
Quadratus Femoris
Rectangular/Quadrangular shaped muscle
Inferior
Innervation directly from sacral plexus
Origin: Ischial Tuberosity
Insertion: Quadratic tubercle (intertrochanteric crest of femur)
Action: externally rotates thigh
Nerve Supply: nerve to QF (sacral plexus)
Tensor Fascia Lata
Origin: ASIS, iliac crest
Insertion: ITB
Action: Abducts thighh, dynamic stabiliser
Nerve Supply: Superior Gluteal
What is the most inferior part of the ischium?
Ishcial tuberosity
-large protuberance inferiorly
Where is the ASIS located?
Anterior Superior Illiac Spine
Superior spine on the Anterior side of the Illium
Where is the AIIS located?
Anterior Inferior Illic Spine
Inferior spine on the Anterior side of the Illium
Where do the 2x parts of the pubis meet?
Anterior
Comes to meet together at the midline in the Pubis Symphosis
What is the Pubic Symphysis?
Meeting point in the midline of the pubic bones of the pelvis
Where is the Ischial spine located?
superior spine poking posteriorly of the ischium
Where is the Ischial Tuberosity located?
inferiorly
a protuberance poking posteriorly from the Ischium
What is the pelvic part of the hip joint called?
Acetabulum
What are the essential features of the acetabulum?
Pelvic part of the hip joint
Combining point of the 3x components of the hip joint
Triadic Cartilage: Aren’t ossified in utero/children (still cartilaginous) therefore - 3x pieces of cartilage that are yet to join
What is the state of the Acetabulum in Utero/childhood?
Unossified
Triadic Cartilage
-the 3x pieces are unossified, hence are just 3x pieces of cartilage yet to fuse together
What is the name for the Acetabulum in utero/childhood?
Triadic Cartilage
What are the 5x components of the entire boney pelvis?
Hip bones: 1. Ischium 2. Illium 3. Pubis \+ 4. Sacrum 5. Coccyx -all bound together by very strong ligaments
What is the sacrotuberous ligament continuous with?
Posterior Sacroilliac ligament
extends across the sciatic notch, and along with sacrospinous ligament, converts the notch into Greater and Lesser Sciatic Foramina
What 2x ligaments extend across the sciatic notch? and what landmarking affect does this have on the pelvis?
Sacrotuberous ligament (Sacrum –> Ischial tuberosity)
+ Sacrospinous ligament (sacrum –> Ischial spine)
extend across the sciatic notch
Converts notch into Greater and Lesser Sciatic Foramina
What the 2x attachments of the sacrotuberous ligament?
Sacrum –> Ischial Tuberosity (inferior protuberance)
What are the 2x attachments of the sacrospinous ligament?
Sacrum –> Sichial spine
superior spike poking posteriorly
What is the Posterior Sacroilliac ligament continuous with?
Sacrotuberous ligament
What are the 2x attachemnts of the Posteior Sacroilliac ligament?
Posterior/back surface of the pelvis
Superior Posterior Sacrum –> Posterior Superior Illiac Spine
What occurs within the landmark of the Greatest Sciatic Foreamen?
structures EXIT OUT
Superiorly
Lower limb arteries
-superior and inferior gluteal arteries = corresponding nerves, pass superior and inferorior to Piriformus
Nerves from pelvis going into the the gluteal region (e..g sciatic nerve)
Is the greatest sciatic foreamen for Entry or Exit of structures?
EXIT/ OUT
-e.g. superior and inferior gluteal arteries + corresponding nerves (sciatic nerve) pass superior and inferior to piriformis
What is the example nerve which runs out of the Greatest sciatic foreamen?
Sciatic nerve
+ superior and inferior gluteal arteries + corresponding nerves (sciatic nerve) pass superior and inferior to piriformis
What occurs within the landmark of the Lesser Sciatic Foreamen?
structures Entering INTO this opening
Inferiorly
e.g. into Genitourinary system or Peroneum
-entering or leaving the Peroneum, so supply the peroneum
e.g. Pudendal Nerve
-superior leaves pelvis via greater s.f., but hooks around and Enters pelvis via Lesser sciatic foramen
What are the 2x structures going Into the Lesser sciatic foreamen genreally going to?
- Genitourinary system
typically: 2. Peroneum
(entering or leaving the peroneum to supply the peroneum)
e.g. Pundendal Nerve
What is the example nerve which runs into the Lesser sciatic foreamen?
Pundendal Nerve
Leaves pelvis via greater s.f.
But hooks around and enters pelvis via Lesser sciatic foreamen
Through which landmark is the Peroneum supplied in the pelvis?
via ENTERY (mainly) and exit of vessels through the LESSER sciatic foreamen (e.g. Pundendal nerve) to supply the peroneum
What are the 6x Short External Rotators of the thigh?
- Pirformis
- Superior Gemeli
- Inferior Gemeli
- Obturator Internus
- Obturator Externus
- Quadratus Femoris
What are the 2x layers of muscle in the gluteal region?
- Superficial layer = Gluteus/gluteal muscles
2. Deep Layer= Hip rotators
Are the gluteal muscles part of the superficial or deep layer of muscles in the gluteal region?
Superficial = gluteal muscles in gluteal region
Are the hip rotator muscles part of the superficial or deep layer of muscles in the gluteal region?
Deep= hip rotator muscles in gluteal region
What is the largest and most powerful muscle in the body?
Gluteus maximus
very powerful
Hip Extensor - standing up from sitting down, walking up stairs
Nerve supply: Inferior gluteal nerve
What is the nerve supply for the Gluteus Maximus muscle?
Inferior Gluteal Nerve
What is the name of the primary abductor of the hip joint?
Gluteus Medius
Contraction = moving the Femur out Laterally
- helps to Hold/keep the Pelvis Level when Walking
Problem: Abductor Lurch/Gluteus Medius Lurch
What muscle is affected during a lurching gate?
Gluteus Medius
Trendelenburg Gait/Abductor Lurch/ Gluteus Medius Gate
Leaning, one side taking all the weight, Pelvis isnt being held level during walking
What is the Trendelenburg Gait/Abductor Lurch/Gluteus Medius Gate involving?
Gluteus Medius affected
- is the Primary abductor of the hip joint, functions to hold the hip level when walking
Pelvic stabilisation
Injury to muscle or nerve supplying it (superior gluteal nerve)
=thigh abduction weakened as gluteus medius no longer contracts to support the pelvis and stop it from tilting to lifted side
-results in a Leaning to Unaffected side “the sound side sags” when walking. In order to clear the leg on the unaffected side during Swing through phase.
As other leg/side takes all the weight. Pelvis isnt being held level during walking- failure to have complete abduction
What is the nerve supply for Gluteus Medius?
Superior Gluteal Nerve
What is the action the Gluteus Medius muscle?
ABDuctor of the hip
Contraction = making Femur move out Laterally
What are an example of both internal and external rotation?
Internal rotation = pointing toes inwards/towards midline
External rotation = pointing toes out laterally/ outwards. Ballet 1st position
What 4x Short External rotator muscles are located inferior to Piriformis?
- Gemellus Superior
- Gemellus Inferior
- Obturator Internus
-3x separate origins.
-1x Common insertion- form 1x combined 3x headed tendon on to Greater Trochanter of Femur
All external rotator muscles of the hip joint - Quadratus Femoris
All have Common innervation Directly from the Sacral Plexus (including piriformis)
What is the relationship between Gemellus Superior and Inferior and Obturator Internus?
All External rotators
3x different origins
1x common Insertion. Greater trochanter of femur. combine to form single tendon with 3x heads medially
What is the common insertion point of the 3x headed muscle of the 3x inferior external rotators of the hip?
Greater trochanter of the femur
Gemellus Superior, Inferior and Obturator Internus
-3x different origins, 1x common insertion as fuse to form single tendon (with 2x medial heads(origins))
What is the innervation for the Short External Rotator muscles of the hip inferior to Piriformis?
Innervation Directly from the Sacral plexus
Gemellus Superior and Inferior, Obturator Internus and Quadratus Femorus
Which muscles receive direct innervation from the sacral plexus?
Short External Rotator muscles of the Hip
- Gemellus Superior
- Gemellus Inferior
- Obturator Internus
- Quadratus Femoris
- Priformis
What muscles is pear shaped in the hip?
Piriformis
-comes out through the sciatic notch in the sacrum to insert onto the femur
Which muscle in the hip comes out through the sciatic notch in the sacrum and inserts onto the femur?
Piriformis
- pear shaped muscle
- short external rotator (of hip joint)
- innervated directly by the sacral plexus
What are the 4x Posterior Thigh muscles?
- Biceps Femoris
- Semi-tendinosus
- Semi-membranosus
- Adductor Magnus
Biceps Femoris
Origin: Long Head: Ischial Tuberosity. Short Head: Linea Aspera
Insertion: Head of Fibula
Action: Flexes and externally rotates leg at knee (rotates leg at knee; extends thigh at hip)
Nerve Supply: Sciatic Nerve. Long Head BF: Tibial nerve. Short Head BF: Peroneal Nerve
What origin and nerve supply for the Long Head of biceps femoris?
Origin: Ischial Tuberosity
Nerve Supply: Tibial nerve
What is the origin and nerve supply for the short head of biceps femoris?
Origin: Linea Aspera (comes off 1/2 way down Linea Aspera and is attached to the Deep fascia)
Nerve Supply: Common Peroneal Nerve
Semitendinosus
Origin: Ischial Tuberosity
Insertion: Superior Part of Medial Tibia (Pes Anserinus)
attaches to front/medial side of knee- next to satorius and gracilis
Action: Flexes and internally rotates leg. Extends thigh
Nerve Supply: Tibial Nerve ( branch of sciatic)
Semimembranosus
Fleshier/Less Tendinus
Deeper of the two
Origin: Ischial Tuberosity
-partially swings across the back of the knee
Insertion: Medial condyle of tibia - Wider attachment across posterior aspect of the knee
Action: Flexes and internally rotates leg. Extends thigh.
Nerve Supply: Tibial NErve (branch of sciatic)
Adductor Magnus
Origin: Adductor part= Inferior Pubic Ramus
Hamstring part = Ischial Tuberosity
Insertion: Linea Aspera, Medial Supra condylar ridge, Adductor Tubercle
Action: Adducts thigh, can both flex and extend thigh by different fibres
Nerve Supply: Adductor part= Obturator Nerve. Hamstring part=Sciatic Nerve
What is the origin and nerve supply of the Adductor part of Adductor Magnus?
Origin: Inferior Pubic Ramus
Nerve supply: Obturator Nerve
What is the origin and nerve supply of the Hamstring part of Adductor Magnus?
Origin: Ischial Tuberosity
Nerve Supply: Tibial nerve (branch off sciatic nerve)
Where do the gluteal arteries arise from?
Internal Illiac Arteries
What is the relationship between the structures exiting/going out of the greater sciatic foreamen and the piriformis?
Leave/Exit/Out of
Superior and Inferior Gluteal Arteries
+ corresponding nerves (sciatic nerves)
pass superior and inferior to piriformis
What anastomosing occurs of the arteries around the hip?
Superior and Inferior Gluteal arteries anastomes
Then S&I G.A. anastomose with the Circumflex arteries (branches of profunda femoris)
What are the circumflex arteries branches of? and what do they anastomose with?
Circumflex arteries = branches off profunda femoris artery
anastomose with superior and inferior gluteal arteries, after both sets have anastomosed themselve
What are the branches off the Profunda Femoris arteries called?
Circumflex arteries
What is the location and function of the Superior Gluteal artery?
Leaves via Greater Sciatic Foreamen
Leaves Laterally
runs Superior to Piriformis
supplies Gluteus Medius and Minimus
What is the location and function of the Inferior Gluteal Artery?
Leaves vie Greatest Sciatic foreamen
Leaves Laterally
runs Inferior to Piriformis
supplies Gluteus Maximus
What are the essential features of the sciatic nerve?
Largest nerve in the body
Continuation of the main part of the sacral plexus
Under gluteal region. Under Gluteus Maximus
Inferior to Piriformis (10-20% have sciatic nerve superior/through piriformis)
Well protected
as is Very important for the functioning of the Lower Limb
Own artery running with it - as is so big - called “Artery to sciatic nerve” - a branch of Inferior Gluteal artery
Deep from hamstring to knee, Posterior aspect of thigh
Divides usually in Distal thigh, but can be higher - needs to be considered during surgery otherwise can be injured
What is the largest nerve in the body?
Sciatic Nerve
What is the location of the Sciatic nerve relative to piriformis?
Inferior to Piriformis, Under Gluteal region and gluteus Max
10-20% of people have sciatic nerve running superior/through piriformis
What occurs in 10-20% of the population regarding the relationship between sciatic nerve and piriformis
Normally sciatic nerves runs INFERIORLY to piriformis
but 10-20% of population of sciatic nerve running superiorly/through piriformis
What is the location of the sciatic nerve through the leg?
Deep from hamstring to knee runs on Posterior aspect of the thigh Well protected has its own artery as is so big important to the functioning of the lower limb
What is the the sciatic nerve important for the functioning of?
Sciatic nerve is important for the function of the lower limb
- continuation of main part of sacral plexus
What is the name for the continuation of the main part of the sacral plexus?
Sciatic nerve
What is the sciatic nerve a main continuation of?
Sacral plexus
–> main continuation is sciatic nerve
What is the name of the sciatic nerves artery and where does it originate from?
Artery to sciatic nerve
from Inferior Gluteal Artery
What is the relationship between the sciatic nerve and the gluteal region?
Sciatic nerve is under gluteal muscles and gluteus maximus
80-90% of the time Inferior to Piriformis (otherwise runs superior/through)
Where does the Sciatic nerve usually divide?
Distal thigh
but can sometimes occur much higher
therefore needs to be considered during surgery to avoid injury
Even if the sciatic nerve hasnt divided into the thigh, the parts of the sciatic nerve that supply the hamstrings are going to go on and become the tibial nerve
What needs to be considered during surgery of the thigh to avoid neural injury?
The location of Sciatic nerve branching
usually branches into tibial and common peroneal(fibular) nerve distally, but can occur higher
therefore needs to be considered to avoid injury during surgery
Where is the origin of the Short head of Biceps Femoris?
Comes off 1/2 way down the Femur
and is also attached to the Deep fascia
Is biceps femoris medial or lateral to the knee?
Lateral
When sitting what structure do you sit down on?
NOT Gluteus maximus
Flex hip fully forward, muscles slide up and forward, sit on ischial tuberosity
–> therefore painful when you sit too long, as you dont have much muscle sitting there + varying amounts of adipose tissue
What is the relationship between flexion, sitting, ischial tuberosity and gluteus Maximus?
Sitting = flex hip forward= all muscles slide superiorly and forward
Not sitting on Gluteus maximus
Just sitting on ischial tuberosity
–> therefore get painful when you sit too long as you’re not sitting on muscle + varying amounts of adipose tissue
Why cant you sit for too long?
Actually sitting on ischial tuberosity
Sitting = Flexion of hip = muscles slide superiorly and forwards
Not sitting on a muscle or gluteus maximus
–> therefore you get pain if sitting too long as no muscle + varying amounts of adipose tissue
Why is the ischial tuberosity so large?
Both semitendinosus and Semimembranosus originate off there
- so many muscles pulling on it
What is the common origin of semitendinosus and semimembranosis?
Ischial tuberosity
-they make the ischial tuberosity so big as it has so many muscles pulling on it
Where does SemiTENdinosus insert?
Medial side of knee
next to Satorius and Gracilis (coming in from front and medial side) Pes Anserinus
What is the relationship between Satorius, SemiMEMbranosus and Gracilis?
All 3x attach on the medial side of knee
Pes Anserinus
What 2x compartments are adductor magnus part of?
Posterior and Medial compartment
Comes off the ishcial tuberosity
What are the essential features of the hamstring muscles?
Cross 2x joints - hip and knee attach to pelvis posteriorly insert Below knee Knee Flexion and Hip Extension All supplied by tibial nerve
Which muscle in the thigh crosses 2x joints?
Hamstring muscles
Posteriorly attach to pelvis - and cross hip joint
Insert below knee - cross Knee joint
Knee Flexion and Hip Extension
What nerve supplies the hamstring muscles?
Tibial nerve (from sciatic nerve)
What movements to the hamstring muscle lead to?
Hip Extension and Knee Flexion
as crosses both joints
attaches posteriorly to ischial tuberosity (crosses hip joint)
inserts below knee (crosses knee joint)
Summary of Trendelenburg Gait
Gluteus Medius normally contracts to support and stabilize pelvis
Weakened thigh abduction
Gluteus Medius no longer contracts and supports and stabilizes pelvis.
Doesnt stop it from tilting to the unaffected side “the sound side sags” - during SWING phase of gait cycle
-in order to try and clear the leg
Where is the safe side for intragluteal injections and what structure determines the safety of lack of it?
SuperioLateral side
Lateral side = safe for sciatic nerve
superior as Gluteal region is a common site for intramuscular injections as Large muscle area for venous absorption
Where is the safe side of the butt regarding the Sciatic nerves and intramuscular injections?
LAteral part of buttocks
-hence superiolateral intragluteal muscle injections
Why is the gluteal muscles a common area for intramuscular injections?
Gluteal muscles are a Large muscle area for Venous absoprtion
Where is a large muscle area, good for venous absorption, utilized for intramuscular injections?
Gluteal muscles
Superiolateral = safe= avoids sciatic nerve
What is piriformis syndrome?
Sciatic nerve is compressed by piriformis muscle
Pain, tingling and numbness in buttocks and down path of sciatic nerve (lower thigh and into leg)
What is the condition called when the piriformis muscle is compressing a nerve, leading to pain, tingling and numbness?
Piriformis syndrome Nerve=sciatic nerve pain, tingling and numbness occur in 1. buttocks 2. down the path of the sciatic nerve, into lower thigh and leg
When do hamstring injuries usually occur?
Kicking or running sports
-sudden change from stationing to sprinting
-kicking against resistance(football or person)
Midsubstance strains or tears within the muscle
-can strain pretty easily
can avulse the ischial tuberosity completely
