Session 6: The Hip, Buttock and Thigh Flashcards
What is important in terms of the development if the lower limb?
- Twisting of the lower limb during development:
permanent pronation at the mid-thigh level makes the terminology in the lower limb confusing. - Everything below the hip joint is back to front, things that should be anterior are posterior.
What are the 2 major regions of the lower limb?
- The gluteal region (part of the trunk)
- the “free lower limb” (thigh, leg and foot)
What are the bones of the region?
The pelvis (the “hip bone”)
- Ischium
- Ilium
- pubis
The femur (the thigh bone)
What is the leg?
- the leg is the area between the knee and the ankle
- the area between the hip and the knee is the thigh
Which bones contribute to the socket of the hip joint?
- pubis, ischium and ilium
- make the acetabulum
Facts about the pelvis
- ossification of bones occurs separately
- ala of the ilium are the external part, fossa is the internal part
- the pubis has a body and 2 arms: the inferior and superior ramus
Femur
- classic long bone
- thigh bone
- head articulates with the acetabulum (-> hip joint)
- 1 condyles on distal end as well as medial and lateral epicondyles.
What are the common femur fractures?
- fracture of the femoral neck - most common
- intertrochanteric fracture
Important ligaments and foramina of the pelvis.
- greater sciatic foramen
- lesser sciatic foramen
- sacrotuberous ligament
- sacrospinous ilgament
The Fascia of the region
There are two layers of fascia
- Superficial fascia – i.e. subcutaneous tissue
- Deep fascia – in the thigh called fascia lata
Fascia lata extends like a stocking beneath the skin
A lateral thickened area of it is called the ilio-tibial tract
What are the muscular compartments of the thigh?
- Gluteal compartment
- Anterior compartment of the thigh
- Medial compartment of the thigh
- Posterior compartment of the thigh
Which muscles are in the gluteal region?
=> The extensors, abductors and external rotators of the hip
Gluteal muscles
- Gluteus maximus
- Gluteus medius
- Gluteus minimus
- (Tensor fasciae latae) -> functions more like an anterior muscle, stabilises knee extension.
Short external (lateral) rotators of the hip
- Piriformis
- Obturator internus
- The gemelli (sup. and inf.)
- Quadratus femoris
Gluteus maximus
Attachments:
- fascia covering gluteus medius, external surface of ilium begin posterior gluteal line, fascia of erector spinae, dorsal surface of lower sacrum, lateral margin of coccyx, external surface of sacrotuberous ligament.
- posterior aspect of iliotibial tract of fascia late and gluteal tuberosity of proximal femur.
- superficial 3/4 of gluteus maximus attaches to the iliotibial tract, the deep distal 1/4th attaches to the gluteal tuberosity of the femur.
Innervation:
- L5,S1,S2 (inferior gluteal nerve)
Function:
powerful extensor of flexed femur at hip joint; lateral stabiliser of hip joint and knee joint; laterally rotates and abducts thigh.
- biggest muscle in the body
- coarse fibers (not fine movements)
What are the short external (lateral) rotators of the hip similar to in the upper limb?
- rotator cups muscles
- help hold the head of the femur in the acetabulum
- but also have other functions.
Gluteus minimus and medius
- attach to the greater trochanter of the femur
- innervated by the superior gluteal nerve (L4,5,S1)
- function: abducts femur at hip joint; holds pelvis secure over stance leg and prevents pelvic drop on the opposite swing sie during walking. medially rotates the thigh.
What are the muscles in the anterior compartment of the thigh?
=> Hip Flexors and Knee Extensors
Pectineus
Ilio-psoas
(Tensor fasciae latae)
Sartorius (ASIS to medial part of knee; most superficial muscle of the anterior compartment)
Quadriceps femoris (attach in patella area)
- Rectus femoris
- Vastus medialis
- Vastus intermedius
- Vastus lateralis
Iliopsoas muscle
- the psoas major and the iliac muscles originate on the posterior abdominal wall and descend into the upper part of the anterior compartment of the thigh through the lateral half of the gap between the inguinal ligament and the pelvic bones.
- originate as separate muscles in the abdomen but both insert into a common tendon onto the lesser trochanter of the femur and together are referred to as the iliopsoas muscle.
Compartment syndrome
- occurs when there is swelling within a fascial enclosed muscle compartment in the limbs.
- typical causes include limb trauma, intracompartment haemorrhage and limb compression.
- as pressure in the compartment elevates. capillary BF and tissue perfusion is compromised which can ultimately lead to neuromuscular damage if not treated.
Adductor canal
= (Hunter’s Canal, Subsartorial Canal)
Extends along the medial aspect of the thigh
Formed by:
- Vastus medialis (anteriorly)
- Adductor longus and adductor magnus (posteriorly)
- Sartorius (medially)
Contains:
- Femoral artery
- Femoral vein
- Saphenous nerve
Which muscles are in the medial compartment of the thigh?
=> Hip adductors
Adductor longus Adductor brevis Adductor magnus Gracilis Obturator externus
Quadriceps
- vastus muscles originate from the femur; attach first to the patella by the quadriceps femoris ransom and the to the tibia by the patellar ligament.
- vastus muscles cross knee joint, RF also crosses the hip joint.
- rectus femoris originates from the pelvic bone.
Which muscles are in the posterior compartment of the thigh?
=> Knee Flexors and Hip Extensors
“The Hamstrings”
Semimembranosus
Semitendinosus
Biceps femoris
The femoral triangle
Outlined by:
- Superiorly – the inguinal ligament
- Medially – adductor longus
- Laterally - sartorius
Contains:
- Femoral nerve
- Femoral artery
- Femoral vein
mnemonic: NAVY
ligaments, foramina and notches in the gluteal region
Greater sciatic notch Lesser sciatic notch Greater sciatic foramen and lesser sciatic foramen Sacrotuberous ligament Sacrospinous ligament
What is the importance of the greater and lesser sciatic foramina?
- Greater sciatic foramen: structures passing from the pelvis to the thigh
- Lesser sciatic foramen: structures passing from the pelvis to the perineum
- The Sciatic Nerve!
The Sciatic nerve
- Passes from pelvis to buttock via greater sciatic notch/foramen
- In the buttock, lies in the inferior and medial quadrant
- Passes along posterior aspect of the thigh
- Divides into the tibial nerve and the common peroneal nerve (inconstant level)
- Supplies all the hamstring muscles and all the muscles below the level of the knee
- If injecting in the buttock, use the superior and lateral quadrant
- The sciatic nerve normally enters the gluteal region inferiorly to piriformis muscle, but can be superior or pierce the muscle itself.
- Variations of the emergence of the sciatic nerve from the pelvis interior to the gluteal region.
- For this reason, care must be taken to avoid the nerve during intramuscular injection.
Which muscle does a gluteal i.m. injection usually go into?
- gluteus medius
Trendelenberg test
The Hip Abductors – Trendelenberg test:
the abductors of the thigh prevent tilting of the pelvis when a limb is raised.
The hip joint
- Synovial ball and socket joint
- Head of the femur and the acetabulum
- Acetabular labrum
- Transverse acetabular ligament
- 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
- the socket is not complete which is made up IRL by a ligament (ligament of th head of femur?)
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
capsular ligaments of the hip joint
- attach spirally
- iliofemoral, pubofemoral, ischiofemoral (latter one posteriorly)
Blood supply to the head of the femur
- Medial and lateral circumflex arteries
- The artery of the head of the femur (more important in children)
- Damaged in intracapsular fractures of the femoral neck
- Avascular necrosis of the femoral head
- some from the obturator A; majority from the circumflex femoral A.
Which muscles are the hip flexors?
Ilio-psoas Sartorius Tensor fascia lata Rectus femoris Adductor longus Adductor brevis Adductor portion of adductor magnus gracilis
Which muscles are the hip adductors?
Adductor longus Adductor brevis Adductor magnus Gracilis Pectineus Obturator externus
Which muscles are the hip extensors?
The hamstrings – semimembranosus, semitendinosus, biceps femoris
Posterior part of adductor magnus
Gluteus maximus
Which muscles are the hip abductors?
Gluteus medius
Gluteus minimus
Tensor fascia lata
Which muscles are the hip external rotators?
Obturator internus and obturator externus The Gemelli Piriformis Quadratus femoris Gluteus maximus
Which muscles are the hip internal rotators?
Anterior portion of gluteus medius
Anterior portion of gluteus minimus
Tensor fascia lata
Arteries of the 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
course of the femoral artery and vein
- 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.
Veins of the region?
Superficial veins
Long saphenous vein
Joins the femoral artery at the sapheno-femoral junction
Valve!
Deep veins Popliteal vein Femoral vein External iliac vein Sapheno-femoral junction Venae comitantes of the profunda femoris artery
Lymphatic drainage of the region
Lymph flows with the superficial and deep veins
Superficial inguinal lymph nodes
Deep inguinal lymph nodes
External iliac lymph nodes
(inguinal, (also drain the pubic area), some at the knee as well)
Where do the nerves to the lower limb emerge from?
the lumbosacral plexus
Nerves in the lower limb
- Femoral n. supplies anterior compartment of thigh.
- Obturator n. supplies medial (adductor) compartment of thigh.
- Sciatic n. (or its terminal branches Tibial and Common Peroneal ns.) supply the remaining compartments (i.e. post. thigh, ant. and post. leg, foot)
Summary of motor segmental supply
Hip Flexors
L23
Hip Extensors
L45
Knee Extensors
L34
Knee Flexors
L5S1
Motor peripheral supply
Anterior Compartment of the Thigh
- Femoral Nerve
- Posterior divisions of lumbar plexus (L234)
Medial Compartment of the Thigh
- Obturator Nerve
- Anterior divisions of the lumbar plexus (L234)
Posterior Compartment of the Thigh
- Sciatic nerve (L345S12)
Gluteal Compartment of the Thigh
- Superior gluteal nerve (L45S1) – gluteus medius and minimus
- Inferior gluteal nerve (L5S12) – gluteus maximus
Sensory segmental distribution
Dermatomal distribution
Front of the thigh : T12, L123
Back of the thigh : S123
Buttock S234
Sensory peripheral supply
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)
