Session 6: Hip, Buttock, Thigh

Question 1

Bones of the Lower Limb: Pelvic bones

Answer 1

Bony Pelvis:

—The bony pelvis is formed by the

• —Sacrum
• —Coccyx
• —3 pelvic bones
  
  • —Ilium, ischium and pubis

Pelvic bone:

• —Composed of three bones:Ilium, ischium and pubis
• —All of the hip, buttock and thigh muscles relating to hip movement are proximally attached to the pelvic bone

Question 2

Ligaments in the pelvic area

Answer 2

• —Sacrospinous:
  
  • —Between sacrum and ischial spinous process
• —Sacrotuberous
  
  • —Between sacrum and ischial tuberosity
  • —Prevents upward tilting of the sacrum

Question 3

Foramina:

Answer 3

—Greater sciatic foramen

• —Formed by the greater sciatic notch and the ligaments
• —Transmits structures leaving the pelvis to the lower limb
• —Important: Sciatic nerve

—Lesser sciatic foramen

• —Formed by the lesser sciatic notch and the ligaments
• —Transmits structures passing from the pelvis to the perineum

Question 4

Acetabular (hip) Joint:

Answer 4

• —Synovial ball and socket joint between the head of the femur and the acetabulum
• —Similar to the glenohumeral joint it allows all types of movement –
  
  • —Flexion, extension, abduction, adduction, lateral rotation, internal rotation, circumduction
• —Around the rim of the bony acetabulum is an incomplete rim of tissue called the acetabular labrum
• —This is completed by the transverse acetabular ligament

Question 5

Synovium and Ligament of the Femoral Head

Answer 5

• —Synovial membrane surrounding the head
• —The ligament of the head of the femur attaches the femoral head to the acetabulum

Capsule:

• —The membrane is surrounded by a capsule which extends down the neck of the femur
• —Runs further anteriorly than posteriorly
• —Fractures of the hip are intracapsular or extracapsular

Ligaments:

—4 ligaments reinforce this capsule

—Ligament of the femoral head

• —Ilio-femoral ligament
• —Pubo-femoral ligament
• —Ischio-femoral ligament

Question 6

Blood Supply to the Femoral Head:

Answer 6

• —The blood is supplied by 2 branches of the profunda femoris
  
  • —Lateral circumflex artery
  • —Medial circumflex artery
• —Acetabular branch of the obturator artery*

Question 7

—Superficial gluteal compartment

Answer 7

1. —Gluteus maximus
2. —Gluteus medius
3. —Gluteus minimus

—Gluteus maximus

• —Distal:

—Deep fibres: Gluteal tuberosity

—Superficial fibres: Iliotibial tract

• —Function

—Hip Extension

—Some lateral rotation and abduction

• —Innervation:

—Inferior gluteal nerve

Question 8

—Deep gluteal compartment (Short external rotators of the hip)

Answer 8

1. —Piriformis
2. —Obturator internis
3. —Superior gamellus
4. —Inferior gamellus
5. —Quadratus femoris

—Function: Lateral rotation of hip

—Distal: All attach to greater trochanter

—*Quadratus femoris is technically distally attached to the intertrochanteric crest

—*Proximal: Complex, see earlier slides

—*Innervation: Complex, see sacral plexus slides

Piriformis and Obturator Internus

—They are both part of deep gluteal compartment: short, lateral rotators of the hip

—Piriformis:

• —Proximal: Anterior Sacrum
• —Distal: Medial aspect of greater trochanter
• —Splits the greater sciatic foramen into two parts

—Obturator internus:

• —Proximal: Internal obturator membrane
• —Distal: Medial aspect of Greater trochanter
• —Tendon makes a 90⁰ turn to go through the lesser sciatic foramen

Question 9

Anterior compartment of the thigh

Answer 9

• —Supplied by the femoral nerve
• —Proximal attachment of the hip flexors is the medial ilium

1. —Iliopsoas—*Only the ilacus is suppled by the femoral nerve. The psoas has other innervation
2. —Tensor fascia lata *Supplied by?
3. —Sartorius
4. —Quadriceps femoris
5. —Rectus femoris
6. —Vastus medialis
7. —Vastus intermedius
8. —Vastus lateralis

Question 10

Ilio-psoas

Answer 10

—Anterior compartment of the thigh

—Ilio-psoas (Iliacus and psoas major)

• —Proximal:
  
  • —Iliacus attaches to? —Iliac fossa of anterior ilium
  • —Psoas major attaches to the posterior abdominal wall
• —Distal: Lesser trochanter
• —Function: Hip flexion

Question 11

Fascia

Answer 11

Two layers:

• —Superficial fascia

—Similar to fascia throughout the body. Made up of subcutaneous tissue

• —Deep fascia

—Area of the thigh called the fascia lata

—Extends like a stocking beneath the skin

—Lateral thickened area is the iliotibial tract

Question 12

Tensor Fascia Lata

Answer 12

• —Anterior compartment of the thigh
• —Proximal
  
  • —ASIS
• —Distal

—Iliotibial tract – Attaches to the lateral condyle of the tibia

• —Function - Stabilise the knee in extension
• —Innervation? Superior gluteal nerve

Question 13

Sartorius, Quadriceps Femoris

Answer 13

Sartorius:

• —Anterior compartment of the thigh
• —Proximal: —ASIS
• —Distal: Pes anserinus ligament* on medial tibia inferior to the tibial tuberosity
• —Function: —Hip and knee flexion

Quadriceps Femoris:

Rectus femoris

• —Proximal: AIIS
• —Distal: Quadriceps femoris tendon
• —Function: Hip flexion and knee extension

Vastus medialis, intermedius and lateralis

Proximal: Medial, anterior and lateral femoral shaft respectively

—Lateralis has other proximal attachments*

—Distal: Quadriceps femoris tendon

—Function: Knee extension

Question 14

—Adductor compartment of the thigh

Answer 14

—Supplied by the obturator nerve

1. —Adductor longus
2. —Adductor brevis
3. —Adductor magnus
4. —Gracilis
5. —Obturator externus
6. —Pectineus**

—**This is the exception. This adductor is supplied by the femoral nerve. Hence, Dr Clark places it in the anterior compartment. However, it is actually an adductor in the medial compartment.

Question 15

Adductor Muscles

Answer 15

Adductor Muscles:

Adductor longus, brevis and magnus (adductor component)

• —Proximal: Pubis and ischiopubic ramus
• —Distal: Femoral shaft
• —Function: Adduction and medial rotation of hip joint

Question 16

Gracilis

Answer 16

Gracilis:

• —Medial compartment of the thigh
• —Proximal: Pubis
• —Distal: Medial-proximal tibial shaft
• —Function: Hip adduction and knee flexion

—

Question 17

—Extensor (posterior) compartment of the thigh

Answer 17

—Supplied by the sciatic nerve

—Hamstrings:

1. —Semimembranosus
2. —Semitendinosus
3. —Biceps femoris

—Hamstring component of the adductor magnus

—Considered a hamstring as it is attached to the ischial tuberosity and is supplied by the sciatic nerve

Hamstrings:

Semimembranosus, semitendinosus, biceps femoris and hamstring component of adductor magnus

—Proximal

• —Ischial tuberosity

—Distal

• —Biceps femoris: Fibula
• —Semi-M and semi-T: Tibia
• —Adductor magnus*: Hamstring part attaches to adductor tubercle

—Functions: Knee flexion and thigh extension

Question 18

Femoral Triangle:

Answer 18

—Upside down 3 sided pyramid

—Base of the triangle (superior border of triangle)

• —Inguinal ligament

—Medial border of triangle:

• —Adductor longus

—Lateral border of triangle:

• —Sartorius

—Apex of the triangle (inferior end)

• —Continuous with the adductor canal

—The femoral triangle contains:

—Within the femoral sheath

1. —Femoral artery
2. —Femoral vein
3. —Lymphatics

—Outside of the femoral sheath

1. —Femoral nerve
2. —Psoas major tendon*
3. —Pectineus*
4. —Lateral femoral cutaneous nerve*

Question 19

Adductor Canal:

Answer 19

—The femoral triangle is continuous with the adductor canal

—Sartorius curves around medially to become the anterior border of the adductor canal

• —Hence the adductor canal is sometimes referred to at the “subsartorial” canal

—Borders of the adductor canal

—Anterior

• —Sartorius

—Posterior

• —Adductor longus and magnus

—Laterally

• —Vastus medialis

—Contains

1. —Femoral artery
2. —Femoral vein
3. —Saphenous nerve

—The other branches of the femoral nerve have left to supply the anterior compartment

—Nerve to the vastus medialis*

Question 20

—Define the routes of the femoral artery and profunda femoris

Answer 20

Arterial Supply:

• —Aorta splits into common iliac arteries at L4
• —Common iliacs bifurcate at pelvic brim into internal and external iliacs
• —The external iliac enters the femoral triangle and becomes the femoral artery as it passes under the inguinal ligament
• —The femoral artery is lateral to the femoral vein and medial to the femoral nerve (NAVY)

—Branches in the triangle

1. —Profunda femoris
2. —the superficial circumflex iliac artery*
3. —the superficial epigastric artery*
4. —the superficial external pudendal artery*
5. —the deep external pudendal artery*

—After giving off the profunda femoris is becomes the superficial femoral artery and enters the adductor canal

—At the knee, the superficial femoral becomes the popliteal artery

Palpation:

—The femoral artery can be palpated at the mid-inguinal point

—Halfway between the

• —ASIS
• —Pubic symphysis

—It lies on the psoas tendon and can be “easily” palpated

Profunda Femoris:

• —Arises 4cm distal to the inguinal ligament
• —Gives off two important branches:
  
  • —Lateral femoral circumflex
  • —Medial femoral circumflex

Why are these arteries important?

• —Avascular necrosis of the femoral head
• —Also gives off multiple perforating arteries

Question 21

Venous Drainage

Answer 21

—Superficial: Popliteal vein becomes the femoral vein at the knee

—Deep: The superficial femoral vein receives the venae comitantes of the profunda femoris artery

—Saphenofemoral junction occurs in the femoral triangle

Question 22

Lymph Drainage

Answer 22

—Lymph flows into inguinal nodes

—Superficial inguinal -> Deep inguinal

—Deep inguinal -> External iliac