Region 8 - Hip, Thigh, Gluteal region and Knee Flashcards
How does the sciatic nerve and the gluteal vessels and nerve transition from the pelvis to the lower limb?
Via greater sciatic foramen
How does the femoral nerve and vessels transition from the pelvis to the lower limb?
Via subinguinal space
How does the fobturator nerve and vessels transition from the pelvis to the lower limb?
Obturator canal
What are the root values for the femoral nerve?
Posterior divisions of anterior rami L2-L4
What compartment does the femoral nerve supply?
Anterior thigh
What are the root values for the obturator nerve?
Anterior divisions of anterior rami L2-L4
What compartment does the obturator nerve supply?
Medial thigh
Where does the great saphenous vein start? What forms it?
Dorsum of foot
Formed from union of:
- Dorsal vein of great toe
- Dorsal venous arch of the foot
What is the course of the great saphenous vein?
Ascends:
- Anterior to medial malleolus
- Along anteromedial leg
Passes posterior to medial condyle of femur
Ascends along medial thigh
Transverse saphenous opening in fascia lata
Empties into femoral vein
What veins can drain into the great saphenous vein?
Accessory saphenous vein (may or may not be present)
Some anastomoses with small saphenous vein
Where does the small saphenous vein form? What forms it?
Posterolateral ankle
Dorsal venous arch
What is the course of the short saphenous vein?
Ascends posterior to lateral malleolus Ascends in midline of posterior leg Penetrates deep fascia Ascends between heads of gastrocnemius Empties into popliteal vein
What nerve does the short saphenous vein run alongside?
Sural nerve
What do the medial nodes of the horizontal group of superficial inguinal lymph nodes drain?
Anterior abdominal wall
Lower half of anal canal
What do the lateral nodes of the horizontal group of superficial inguinal lymph nodes drain?
Posterior abdominal wall
What does the vertical group of superficial inguinal lymph nodes drain?
Superficial lower limb
What is the name for the deep fascia of the thigh?
Fascia lata
What is the name for the deep fascia of the leg?
Crural fascia
What is the iliotibial tract?
Lateral thickening of fascia lata
What is the course of the iliotibial tract?
From iliac tubercle
To anterolateral tibial tubercle
What are the functions of the iliotibial tract?
Shared aponeurosis for insertion of:
- Tensor fascia lata
- Gluteus maximus
Supports femur on tibia when standing
What structures form the roof of the femoral triangle?
Fascia lata
Cribriform fascia
Subcutaneous tissue
Skin
What is the saphenous hiatus/opening?
An opening in the fascia lata that allows the great saphenous vein to drain into the femoral vein
What is the structure of the saphenous hiatus?
Lies ~4cm inferolateral to pubic tubercle
Smooth medial margin
Superior, lateral and inferior margin is the falciform margin
Covered by cribriform fascia
What forms the base of the femoral triangle?
Inguinal ligament
What forms the lateral and medial boundaries of the femoral triangle?
Lateral - Sartorius
Medial - Adductor longus
What forms the floor of the femoral triangle?
Iliopsoas (laterally)
Pectineus (medially)
What are the contents of the femoral triangle from lateral to medial?
Femoral: - Nerve - Artery - Vein Lymphatics
What is the femoral sheath?
A fascia surrounding the vascular structures and lymphatics in the femoral triangle
Does NOT surround the femoral nerve
Where does the femoral sheath lie?
Deep to inguinal ligament
What forms the femoral sheath?
Inferior prolongation of the fasciae of:
- Transversalis
- Iliopsoas
How does the femoral sheath end?
Blends with the adventitia of femoral vessels
What is the femoral canal?
A potential space medially within the femoral sheath
What are the contents of the femoral canal?
Lymphatics
Fat
What is the function of the femoral canal?
Allows venous expansion when:
- Increased lower limb venous return
- Increased intra-abdominal pressure causes femoral vein stasis
What are the clinical implications of a femoral canal?
Femoral hernia:
- Abdominal viscerae herniate through femoral ring into femoral canal
What is the bony landmark lying inferior to the lesser trochanter on the posterior femur?
Pectineal line
What bony feature lies between the femoral trochanters on the anterior and posterior aspects of the femur?
Anterior - Intertrochanteric line
Posterior - Intertrochanteric crest
What ‘line’ runs along the posterior femur?
Linea aspera
What does the linea aspera divide into distally?
Medial and lateral supracondylar lines
What muscles of the anterior thigh are the hip flexors?
Iliacus
Psoas major
Pectineus
Sartorius
What are the origins of iliacus?
Iliac crest and fossa
Ala of sacrum
Anterior sacroiliac ligaments
What are the insertions of iliacus?
Psoas major tendon
Lesser trochanter
What is the innervation to iliacus?
Femoral nerve L2-L3
What are the origins of psoas major?
T12-L5 vertebral bodies and IV discs
All lumbar transverse processes
What is the insertion of iliacus?
Lesser trochanter of femur
What is the innervation to psoas major?
Anterior rami of L1-L3
Where does pectineus originate?
Superior ramus of pubis
Where does pectineus insert?
Pectineal line of femur
What is the innervation to pectineus?
Femoral nerve (L2-L3) (Sometimes branch from obturator nerve)
What are the functions of pectineus?
Adducts hip
Flexes hip
Medially rotates hip
What is the origin of sartorius?
ASIS
Where does sartorius insert?
Superior part of medial surface of tibia
What is the innervation to sartorius?
Femoral nerve (L2-L3)
What are the functions of sartorius?
Abducts hip
Flexes hip
Laterally rotates hip
Flexes knee
What are the origins of rectus femoris?
AIIS
Ilium superior to acetabulum
What are the origins of vastus lateralis?
Greater trochanter
Lateral lip of linea aspera
What are the origins of vastus medialis?
Intertrochanteric line
Medial lip of linea aspera
What are the origins of vastus intermedius?
Anterior and lateral surfaces of shaft of femur
What are the insertions of the four quadriceps muscles?
Base of patella:
- Via quadriceps tendon
Indirectly to tibial tuberosity via continuation as patellar ligament
What are the functions of the quadriceps muscles?
All - Extend the knee Rectus femoris: - Flexes hip - Steadies hip joint Vastus medialis: - Distal fibres act to prevent lateral patellar dislocation
What is the innervation to the quadriceps muscles?
Femoral nerve (L2-L4)
What is the pelvic course of the femoral nerve?
Originates with psoas major
Descends posterolaterally in the pelvis to midpoint of inguinal ligament
What is the course of the femoral nerve as it leaves the pelvis?
Deep to inguinal ligament into femoral triangle
Medial to ASIS
On iliopsoas tendon
Lateral to femoral vessels
What are the branches of the femoral nerve?
Muscular branches -> Anterior thigh Articular branches -> Hip and knee Cutaneous branches -> Anteromedial thigh Saphenous nerves: - Cutaneous branch to anteromedial knee, leg and foot
What is the course of the saphenous nerve?
Passes through adductor canal
Becomes superficial by passing between sartorius and gracilis
What are the medial thigh muscles?
Hip adductors:
- Gracilis
- Adductor longus, brevis and magnus
Obturator externus
What are the origins of gracilis?
Body of pubis
Inferior ramus of pubis
What is the insertion of gracilis?
Superior part of the medial surface of the tibia
What is the innervation to gracilis?
Obturator nerve (L2-L3)
What are the functions of gracilis?
Adducts hip
Flexes knee
(Also helps medially rotate hip)
What is the origin of adductor longus?
Body of pubis inferior to pubic crest
What is the insertion of adductor longus?
Middle 1/3 of linea aspera
What is the innervation of adductor longus?
(Anterior division of) obturator nerve (L2-L4)
What is the function of adductor longus?
Adducts hip
What are the origins of adductor brevis?
Body of pubis
Inferior ramus of pubis
What are the insertions of adductor brevis?
Pectineal line
Proximal part of linea aspera
What is the innervation to adductor brevis?
(Anterior division of) obturator nerve (L2-L4)
What are the functions of adductor brevis?
Adducts hip
Assists in flexing hip
What are the origins of adductor magnus?
Adductor part: - Inferior ramus of pubis - Ramus of ischium Hamstrings part: - Ischial tuberosity
What are the insertions of adductor magnus?
Adductor part: - Gluteal tuberosity - Linea aspera - Medial supracondylar line Hamstring part: - Adductor tubercle of femur
What is the innervation to adductor magnus?
Adductor part:
- (Posterior division of) obturator nerve (L2-L4)
Hamstrings part:
- Tibial part of sciatic nerve (L4)
What are the functions of adductor magnus?
Adducts thigh
Adductor part also flexes hip
Hamstring part also extends hip
What are the origins of obturator externus?
Margins of obturator foramen
External surface of obturator membrane
What is the insertion of obturator externus?
Trochanteric fossa of femur
What is the innervation to obturator externus?
Obturator nerve (L3-L4)
What are the functions of obturator externus?
Laterally rotates thigh
Steadies head of femur in acetabulum
What are the root values of the obturator nerve?
Anterior rami of L2-L4
What is the course of the obturator nerve?
Runs in extraperitoneal fat along lateral pelvic wall to the obturator canal (In obturator membrane)
What does the obturator nerve branch into?
Anterior and posterior branches relative to adductor brevis
Muscular branches -> Medial thigh
Cutaneous branch of ant. division -> Middle part of medial thigh
What is the alternative name for the adductor canal?
Subsartorial canal
What is the extent of the adductor canal?
Extends from apex of femoral triangle to adductor hiatus
What muscle does the adductor canal underlie?
Distal 1/2 of sartorius
What are the boundaries of adductor canal?
Medial - Sartorius (also forms roof) Anterolateral - Vastus medialis Posterior: - Adductor longus - Adductor magnus
What are the contents of the adductor canal?
Femoral vessels
Saphenous nerve
What is the adductor hiatus?
Opening between distal insertions of adductor and hamstring parts of adductor magnus
What is the function of adductor hiatus?
Allows passage of femoral vessels from anterior thigh to popliteal fossa
Why doesn’t the saphenous nerve pass through the adductor hiatus?
It passes through sartorius to the anteromedial knee, leg and foot
Where does the femoral artery begin?
It is a continuation of external iliac artery after inguinal ligament
Where does the femoral artery become the popliteal artery?
Adductor hiatus
What does the femoral artery supply?
Anterior and anteromedial thigh
What surface of the femoral artery does profunda femoris originate from?
Lateral or posterior surface
Where does profunda femoris run?
Deep to adductor longus
What are the branches of profunda femoris?
3 or 4 perforating branches through adductor magnus
Medial and lateral circumflex femoral arteries
Where does the obturator artery arise?
From internal iliac artery
What does the anterior division of the obturator artery supply?
Medial compartment
What does the posterior division of the obturator artery supply? Why?
Posterior compartment and adductor magnus
All attach to ischial tuberosity
What arteries contribute to the cruciate anastomosis?
Inferior gluteal
Medial circumflex femoral
Lateral circumflex femoral
1st perforating branch of profunda femoris
Where is the cruciate anastomosis?
Upper posterior thigh
What is the angle of inclination of the femur?
Angle between:
- Long axis of head and neck of femur
- Long axis of shaft
What is the value for the angle of inclination of femur?
~120 degrees
Why is the angle of inclination of the femur smaller in females?
Wider pelvis means long axis of shaft of femur begins more laterally
What is the angle of anteversion/torsion of the femur?
Head angled anteriorly to femoral condyles
What is the value for the angle of anteversion/torsion of the femur?
12 degrees
What muscles in the gluteal region are lateral rotators of the hip?
Gluteus maximus Piriformis Obturator internus Gemelli Quadratus femoris
What muscles in the gluteal region are medial rotators and abductors of the hip?
Gluteus medius
Gluteus minimus
What muscle in the gluteal region acts as support?
Tensor fasciae latae
What are the origins of gluteus maximus?
Ilium posterior to posterior gluteal line (external surface)
Sacrum (and coccyx)
Sacrotuberous ligament
What are the insertions of gluteus maximus?
Iliotibial tract:
- Most fibres (~3/4) -> Lateral condyle of tibia
Gluteal tuberosity of femur (1/4)
What is the innervation to gluteus maximus?
Inferior gluteal nerve (L5-S2)
What are the functions of gluteus maximus?
Extends thigh (especially if flexed) Assists in lateral rotation of hip
What are the origins of tensor fascia lata?
Anterior iliac crest
ASIS
What is the insertion of tensor fascia lata?
Iliotibial tract:
- To the lateral condyle of tibia
What is the innervation to tensor fascia lata?
Superior gluteal nerve (L4-S1)
What are the functions of tensor fascia lata?
Tenses fascia lata and iliotibial tract
Supports femur on tibia when standing
What is the origin of gluteus medius?
Ilium between anterior and posterior gluteal lines (external surface)
What is the insertion of gluteus medius?
Lateral surface of greater trochanter
What is the innervation to gluteus medius?
Superior gluteal nerve (L4-S1)
What are the functions of gluteus medius?
Abducts hip
Medially rotates hip
What is the origins of gluteus minimus?
Ilium between anterior and inferior gluteal lines (external surface)
Where does gluteus minimus insert?
Anterior surface of greater trochanter
What is the innervation to gluteus minimus?
Superior gluteal nerve (L4-S1)
What are the functions of gluteus minimus?
Abducts hip
Medially rotates hip
What are the origins of piriformis?
Anterior sacrum
Sacrotuberous ligament
What is the insertion of piriformis?
Superior border of greater trochanter
What is the innervation to piriformis?
Nerve to piriformis (anterior rami S1-S2)
What are the functions of piriformis?
Lateral rotation of hip (when extended)
[Abducts hip (when flexed)]
What are the origins of obturator internus?
Pelvic (internal) surface of obturator membrane and surrounding bones
What is the insertion of obturator internus?
Medial surface of greater trochanter -> Trochanteric fossa (via lesser sciatic foramen)
What is the innervation to obturator internus?
Nerve to obturator internus (L5-S1)
What are the functions of obturator internus?
Laterally rotates hip Abducts hip (when flexed)
What are the origins of the gemelli muscles?
Superior gemellus:
- Ischial spine
Inferior gemellus:
- Ischial tuberosity
What are the insertions of the gemelli muscles?
Medial surface of greater trochanter (blend with obturator internus tendon)
What is the innervation to the gemelli muscles?
Superior gemellus:
- Nerve to obturator internus (L5-S1)
Inferior gemellus:
- Nerve to quadratus femoris (L5-S1)
What is the function of the gemelli muscles?
Laterally rotate hip
What is the origin of quadratus femoris??
Lateral border of ischial tuberosity
What are the insertions of quadratus femoris?
Quadrate tubercle of intertrochanteric crest and an area inferior to it on femur
What is the innervation to quadratus femoris?
Nerve to quadratus femoris (L5-S1)
What is the function of quadratus femoris?
Laterally rotate hip
Where does obturator externus originate?
External obturator membrane
What is the insertion of obturator externus?
Trochanteric fossa
What is the innervation to obturator externus?
Obturator nerve (L3-L4)
What is the function of obturator externus?
Laterally rotates hip
Where do the branches of the sciatic nerve leave?
Tibial division BELOW piriformis Common fibular division can leave: - Below piriformis - Above piriformis - Through piriformis
What is the course of the superior gluteal vessels and nerves?
Leave greater sciatic foramen above piriformis
Course laterally in plane between gluteus medius and minimus
What is the course of the inferior gluteal vessels and nerves?
Leave greater sciatic foramen below piriformis
Course deep to inferior part of gluteus maximus
What are the root values of the posterior cutaneous nerve of thigh?
Anterior and posterior rami of S1-S3
Where does the posterior cutaneous nerve of thigh lie in relation to the sciatic nerve?
On its posterior surface
What is the cutaneous distribution of the posterior cutaneous nerve of thigh?
Inferior 1/2 of buttocks (via inferior cluneal nerves)
Posterior thigh and popliteal fossa
Lateral perineum and upper medial thigh (via perineal branch)
What is the pelvic articular surface of the hip joint known as?
Lunate surface of acetabulum
What lies in the middle of the pelvic part of the hip joint?
Fat pad in acetabular fossa
What lies around the rim of the pelvic articular surface of the hip joint?
Acetabular labrum
What structure courses between the two ends of the pelvic surface of the acetabulum? What does it bridge?
Transverse acetabular ligament
Bridges acetabular notch
What are the proximal attachments of the fibrous layer of the hip joint capsule?
Just peripheral to acetabular rim
Transverse acetabular ligament
What are the distal attachments of the fibrous layer of the hip joint capsule?
Anteriorly:
- Along intertrochanteric line and root of greater trochanter
Posteriorly:
- Just proximal to intertrochanteric crest (NOT on it)
Where does the iliofemoral ligament lie in relation to the hip joint?
Anteriorly
Superiorly
What is the shape of the iliofemoral ligament?
Y-shaped
What are the proximal attachments of the iliofemoral ligament?
ASIS
Acetabular rim
What is the distal attachment of the iliofemoral ligament?
Intertrochanteric line
What are the bands of the iliofemoral ligament?
Upper
Lower
What are the functions of the iliofemoral ligament?
Act to limit:
- Extension
- Lateral rotation
- Adduction (upper band)
- Abduction (lower band)
Where does the pubofemoral ligament lie in relation to the hip joint?
Anteriorly
Inferiorly
What is the proximal attachment of the pubofemoral ligament?
Iliopubic eminence
What is the distal attachment of the pubofemoral ligament?
Lower intertrochanteric line (blends with joint capsule)
What are the functions of the pubofemoral ligament?
Acts to limit:
- Extension
- Lateral rotation
- Abduction
Where does the ischiofemoral ligament lie in relation to the hip joint?
Posteriorly
What is the proximal attachment of the ischiofemoral ligament?
Ischial spine
Posterior acetabular rim
What is the course of the ischiofemoral ligament?
Spirals superolaterally to medial aspect of greater trochanter
What is the function of the ischiofemoral ligament?
Acts to limit:
- Extension
- Medial rotation
- Adduction
What is the blood supply to the hip joint?
Profunda femoris artery:
- Medial and lateral circumflex femoral arteries
Artery to head of femur
What is the course of the artery to head of femur?
Arises from obturator artery
Runs in ligament to head of femur
What are the hamstring muscles?
Semitendinosus
Semimembranosus
Biceps femoris
What are the functions of the hamstring muscles?
Extend hip
Flex knee
What is the origin of semitendinosus?
Ischial tuberosity
What is the insertion of semitendinosus?
Medial surface of superior part of tibia
What is the innervation to semitendinosus?
Tibial part of sciatic nerve (L5-S2)
What is the origin of semimembranosus?
Ischial tuberosity
What is the insertion of semimembranosus?
Posterior surface of medial condyle of tibia
What is the innervation to semimembranosus?
Tibial part of sciatic nerve (L5-S2)
What are the origins of biceps femoris?
Long head: - Ischial tuberosity Short head: - Linea aspera - Lateral supracondylar line of femur
What is the insertion of biceps femoris?
Lateral side of the head of fibula
What splits the common tendon of biceps femoris?
Lateral (fibular) collateral ligament
What is the innervation to biceps femoris?
Long head:
- Tibial nerve (L5-S2)
Short head:
- Common fibular nerve (L5-S2)
What muscle can laterally rotate knee when flexed?
Biceps femoris
What muscles can medially rotate knee when flexed?
Semimembranosus
Semitendinosus
Gracilis
Sartorius
Where does the sciatic nerve run in the gluteal and posterior thigh regions?
Deep to gluteus maximus and biceps femoris
Where does the sciatic nerve bifurcate?
Apex of popliteal fossa
What forms the roof (posterior boundary) of the popliteal fossa?
Skin
Subcutaneous tissue
Deep fascia
What pierces the deep fascia of the popliteal fossa?
Short saphenous vein
Sural nerve
What structures form the superior border of the popliteal fossa?
Superolaterally - Biceps femoris
Superomedially:
- Semimembranosus
- Semitendinosus (more lateral)
What structures form the inferior border of the popliteal fossa?
Inferolaterally:
- Lateral head of gastrocnemius
Inferomedially:
- Medial head of gastrocnemius
What structures form the floor/anterior border of the popliteal fossa?
Popliteal surface of femur
Capsule of knee joint
Popliteus muscle
What structures are found at the floor of the popliteal fossa?
Oblique popliteal ligament:
- Expansion of semimembranosus
- Reinforces knee joint capsule
Middle genicular vessels
What is the course of the middle genicular vessels?
Pierce joint capsule
Supply:
- ACL
- PCL
What are the contents of the popliteal fossa from medial and deep to lateral and superficial?
Popliteal artery
Popliteal vein (and termination of short saphenous vein)
Tibial nerve
Common fibular nerve
Where does the popliteal artery run from and to?
From adductor hiatus
To inferior border of popliteus
What are the 5 genicular branches of the popliteal artery?
Medial superior Medial inferior Lateral superior Lateral inferior Middle
What is the function of the genicular branches of the popliteal artery?
Form the genicular anastomosis:
- Maintain blood supply to leg when flexed as flexing the knee can kink the popliteal artery
What are the terminal branches of the popliteal artery?
Anterior tibial artery
Posterior tibial artery
What type of joint is the knee joint?
Modified synovial hinge joint
What are the articulations of the knee joint?
Femoropatellar
Femorotibial (x2)
What does the fibrous capsule of the knee joint fuse with anteriorly?
Quadriceps tendon
Patella
Ligamentum patellae
What is the structure of the fibrous capsule of the knee joint posteriorly?
Encloses intercondylar fossa of femur
Open posterior to lateral tibial condyle:
- Allows popliteus attachment
What muscles lie over the medial aspect of the knee? (From anterior to posterior)
Sartorius
Semimembranosus and semitendinosus
Gracilis
What are the attachments of the synovial membrane of the knee joint?
Periphery of articular cartilages of femoral and tibial condyles
Infrapatellar synovial fold
Medial and lateral alar folds:
- Cover inner surface of fat pads on either side of patellar ligament
What bursae of the knee joint are in communication with synovial cavity of the knee joint?
Suprapatellar
Gastrocnemius
Semimembranosus
Popliteus
What are the other bursae of the knee joint?
Subcutaneous prepatellar Subcutaneous infrapatellar Deep infrapatellar Anserine (medial): - Gracilis - Sartorius - Semitendinosus
What are the extracapsular knee ligaments?
Oblique popliteal
Arcuate popliteal
LCL and MCL
What are the intracapsular knee ligaments?
ACL
PCL
What is the oblique popliteal ligament and what does it do?
Expansion of semimembranosus tendon
Reinforces posterior knee capsule
What is the arcuate ligament and what does it do?
Thickening of capsule over popliteus
Strengthens posterolateral joint capsule
What is the origin of the MCL?
Medial epicondyle of femur
What are the insertions of the MCL?
Medial condyle of tibia
Superior medial surface of tibia
Medial meniscus (via deep fibres)
What is the origin of the LCL?
Lateral epicondyle of femur
What is the insertion of the LCL?
Lateral head of fibula
What muscles are related to LCL?
Tendon of popliteus lies deep to it
Tendon of biceps femoris divides in 2 around it
What is the function of the cruciate ligaments?
Maintain contact between femoral and tibial articular surfaces when the knee is flexed
Wind around each other during medial tibial rotation:
- Limit it to 10 degrees
What cruciate ligament is the stronger of the two?
PCL
What is the origin of PCL?
Posterior intercondylar area of tibia
What is the course and insertion of the PCL?
Passes anterosuperiorly
Inserts on anterolateral surface of medial femoral condyle
What are the functions of the PCL?
Prevents femur sliding anteriorly on tibia (especially on flexion) Limits flexion (anterolateral band) Limits extension (posteromedial band)
Where does ACL originate?
Anterior intercondylar area of tibia
What is the course and insertion of ACL?
Extends superiorly, posteriorly and laterally
Inserts on posteromedial surface of lateral femoral condyle by spiralling 110 degrees
What are the functions of ACL?
Prevents femur sliding posteriorly on tibia
Limits medial rotation of femur when foot planted
Limits flexion (anteromedial band)
Limits extension (posterolateral band)
What are the menisci?
Wedges of fibrocartilage
What are the functions of the menisci?
Deepen articular surface
Shock absorption
What are the features of the medial meniscus?
C-shaped
Broad posteriorly
Firmly attached to MCL
What are the features of the lateral meniscus?
Circular
Freely moveable
Attachment for popliteus
What is the blood supply to the knee?
5 genicular branches from popliteal artery
Descending genicular artery from femoral artery
Descending branch from circumflex femoral artery
Recurrent branches from anterior and posterior tibial arteries
