gluteal region and post thigh

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Page 1: GLUTEAL REGION And POST THIGH
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GLUTEAL REGION AND

POSTERIOR THIGH

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Gluteal Region [Buttocks]

Surface Anatomy:1. Iliac crest - boundary

between the postero-lateral abdominal wall and the gluteal area. The bulging curve of the buttocks ends as a deep fold, which distinguishes it from the posterior thigh.

2. Palpate: lateral protuberance of the greater trochanter of the femur.

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Muscles in the Gluteal Region

Gluteus Maximus Muscle Origins: posterior end of the iliac

crest, posterior surface of the sacrum, coccyx and sacro-tuberous ligament.

Insertions: ilio-tibial tract and gluteal tuberosity.

Innervation: inferior gluteal nerve - [L5, S1.2] - emerges below the pyriformis muscle to penetrate the deep surface of the gluteus maximus with accompanying vessels.

Actions - prime extensor of the thigh upon walking, running, standing up from a seated position.

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GLUTEUS MEDIUSAbout half of the muscle is

covered by the gluteus maximus, the anterior half being quite superficial. Verify.

Origins: dorsal surface of the ilium between the anterior and posterior gluteal lines and from the deep fascia.

Insertion: supero-posterior angle of the greater trochanter.

Innervation: superior gluteal nerve [L4, 5, S1] - that emerges above the pyriformis muscle, with accompanying vessels, to penetrate the deep surface of the muscle.

Action - abduction of the thigh. [hip joint]

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GLUTEUS MINIMUS- thinnest, deepest and smallest of

the gluteus muscles. The superior gluteal n.v.s. may be used to identify this muscle, which lies deeper.

Origin: lower part of the dorsum ilii between the anterior and inferior gluteal lines.

Insertion: - the fasciculi converge towards the antero-superior angle of the greater trochanter.

Innervation and action - superior gluteal nerve; abductor of the thigh.

The gluteus medius and minimus muscles help to rotate the pelvis forwards when taking a step.

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Tensor Fascia Lata - small muscle close to the anterior border of the gluteus medius, at the dorsal surface of the ASIS.

Origin: small areas of the dorsum ilii behind the ASIS.

Insertion: ilio-tibial tract.Innervation - superior gluteal

nerve.Action - helps in flexion and

abduction of the thigh.

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Pyriformis - small muscle located deep to the gluteus medius.Origin: antero-lateral surface and border of the sacrum.Insertion: the fibers are directed transversely [laterally] to

emerge from the greater sciatic foramen as a narrow tendon attached to the upper border of the greater trochanter.

Innervation - “nerve to the pyriformis” [S1, 2.]Action - lateral rotator and abductor of the thigh.

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• As a landmark, n.v.s are named superior or inferior as they emerge into the gluteal region above or below the

pyriformis muscle. The large sciatic nerve emerges below it to continue down the thigh and leg.

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Triad of Musculo-tendinous structures below the pyriformis consisting of two small “gemelli” muscles located above and below the tendon of the obturator internus muscle.

For practical purposes, they may be regarded as inserted together at the top of the greater trochanter.

Superior Gemellus - originates from the ischial spine. Some of its fibers are attached to the superior border of the obturator internus tendon.

Tendon of the Obturator Internus - originates around the obturator foramen.

Inferior Gemellus - originates from the posterior end of the ischial tuberosity.

Innervations - “nerve to the obturator internus” [L5 S1, 2]

Actions: lateral rotator and abductor of the thigh [hip-joint]

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Quadratus Femoris - most inferior, thick, quadrangular, short, muscle with transversely directed fasciculi.

Origin: ischial tuberosity.Insertion: quadrate tubercle

[third trochanter] of the femur.

Innervation: “nerve to the quadratus femoris [L4, 5, S1]

Action: lateral rotation of the thigh.

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Neuro-vascular Structures

Superior and inferior gluteal nerves - emerge from the greater sciatic foramen to pass above and below the pyriformis muscle, to course on the deep surfaces of the gluteus medius and maximus muscles.

Superior and inferior gluteal arteries - branches of the hypogastric artery; accompanying veins return the blood to the internal iliac vein; course with the nerves.

Sciatic Nerve - large, long nerve formed by L 4, 5; S1, 2, 3, which divide into anterior and posterior.

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Sciatic Nerve The union of the anterior divisions of L4, 5 S1, 2, 3 form

the “tibial nerve”. The posterior divisions of L4, 5 S1, 2 form the “common

peroneal nerve”.

The Sciatic nerve emerges from the greater sciatic foramen below the pyriformis muscle to course downwards behind superficial to the musculo-tendinous triad and quadratus femoris muscles and descend into the posterior compartment of the thigh.

– A posterior cutaneous nerve to the thigh branches off from the sciatic nerve to course downward along its medial side, to be distributed to the skin on the posterior surface of the thigh down to the popliteal region.

– A “nerve to the hamstrings” may be a differentiated branch that supplies the three muscles of the posterior compartment of the thigh.

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Summary of Muscles (O, I, N, A)

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Muscle Origin Insertion ActionNerveSupply

Gluteus maximus

outer surface ofilium, sacrum, coccyx,sacrotuberous ligament

iliotibial tract,gluteal tuberosityof femur

extends and laterally rotates thigh at hip;through iliotibial tractit extends knee joint

inferior gluteal nerve

Gluteus medius

outer surface of ilium

greater trochanter of femur

abducts thigh at hip; tilts pelvis when walking

superior gluteal nerve

Gluteus minimus

outer surface of ilium

greater trochanter of femur

abducts thigh at hip; anterior fibers medially rotate thigh

superior gluteal nerve

Tensor fasciae latae

iliac crest iliotibial tract assists gluteus maximus inextending the knee joint

superior gluteal nerve

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Pyriformis anterior surface of sacrum

greater trochanter of femur

lateral rotator of thigh

sacral nerve S1 and S2

Superior gemellus

spine of ischium

greater trochanter of femur

lateral rotator of thigh

sacral plexus

Obturator internus

inner surface of obturatormembrane

greater trochanter of femur

lateral rotator of thigh

sacral plexus

Inferior gemellus

ischial tuberosity

greater trochanter of femur

lateral rotator of thigh

sacral plexus

Obturator externus

outer surface of obturatormembrane

greater trochanger of femur

lateral rotator of thigh

obturator nerve

Quadratus femoris

ischial tuberosity

quadrate tubercle on upper end of femur

lateral rotator of thigh

sacral plexus

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Crucial Anastomoses

Formed on the posterior surface of the quadratus femoris by:– A descending branch from the inferior gluteal

artery – Ends of the lateral and medial circumflex

branches of the deep femoral artery.– An ascending branch usually from the first

perforating artery, also from the profunda femoris.

An intramuscular injection in the buttocks is a frequently done procedure. Which of these structures should be avoided? To avoid them, what would be the best site? What precautions should you observe?

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3. The globular area of the buttocks may be divided into 4 quadrants by

these two lines:A horizontal line at the level of the

anterior superior iliac spine.A vertical line crossing the middle

of the horizontal line.Significance: - the upper outer

quadrant is a choice site for intramuscular injections in this region.

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The femoral artery (1) - the principal supply to the anterior compartment of the thigh, as well as the rest of the lower limb.Its branches are: Superficial iliac circumflex (3). This branch travels along the lower border of the inguinal ligament and supplies lower abdomen and upper thigh. External pudendal (2). This branch supplies superficial perineal structures. Lateral femoral circumflex (5). The lateral circumflex travels around the anterior surface of the surgical neck of the femur and anastomoses with the medial circumflex. Medial femoral circumflex (4). The medial circumflex travels around the posterior surface of the surgical neck of the femur. Profunda femoris (6) . The deep (profunda) femoris artery descends along the attached margin of the adductor magnus muscle, giving rise to 3 perforating branches (6a-6c) superior (highest) genicular (7)

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“Hamstring Muscles”

Common name applied to the 3 muscles in the posterior compartment.

They have a common origin from the ischial tuberosity but varies in their insertions.

They are innervated by the nerve to the hamstring.

They also have a common primary function of flexing the leg, but they also help to extend and adduct the thigh.

Their blood supply comes principally from the perforating branches of the deep femoral artery.

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Biceps Femoris - most lateral muscled with a “long head” from the ischial tuberosity, and a “short head” from the middle of the linea aspera and the lateral supracondylar ridge.

The two heads unite to form a common tendon, which deviates lateral to its insertion into the apex of the head of the fibula where it is joined by an extension of the ilio-tibial tract.

The short head receives a branch from the common peroneal nerve; it also helps in the lateral rotation of the leg.

Semitendinosus - usually fusiform, positioned posterior [or superficial] to its twin, tapering distally into a long cylindrical tendon at the popliteal region to be inserted to the upper medial surface of the tibia, adjacent to the attachments of the sartorius and gracilis.

Semimembranosus - usually has a fleshy belly, thicker than its twin, located more anterior [deeper] to it. The fibers form a thick flattened tendon that inserts at the back of the medial condyle of the tibia, the tendon contributes to the formation of the “oblique popliteal ligament” of the knee joint, which reinforces the posterior capsule of the joint.

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Sciatic Nerve The sciatic nerve gives off the nerve

to the hamstring muscles as soon as it enters the posterior compartment of the thigh. At the distal thirds, usually at the superior angle of the popliteal fossa, it divides into its terminal branches:

Common Peroneal [or Lateral Popliteal] Nerve - courses just beneath the tendon of the biceps femoris muscle to its insertion where it divides into a “superficial and a deep peroneal” nerve for the lateral and anterior compartments of the leg, respectively.

Tibial [or Medial Popliteal Nerve] - courses vertically downwards into the posterior compartment of the leg.

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Muscle Origin Insertion ActionNerveSupply

Biceps femoris, long head

ischial tuberosity

head of fibula flexes and laterally rotates leg, extends thigh

tibial part of sciatic nerve

Biceps femoris, short head

shaft of femur

head of fibula flexes and laterally rotates leg

common peroneal nerve

Semi-tendinosus

ischial tuberosity

upper part medial surface of tibia

flexes and medially rotates leg; extends thigh

tibial part of sciatic

Semi-membranosus

ischial tuberosity

medial condyle of tibia

flexes and medially roates leg; extends thigh

tibial part of sciatic

Adductor magnus (hamstring part)

ischial tuberosity

adductor tubercle of femur

extends thigh tibial part of sciatic

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Popliteal Fossa

Lozenge shaped hollow area at the back of the knee; bounded:

a) Superiorly by the diverging hamstring muscles

b) Inferiorly, by the lateral and medial heads of the gastrocnemius muscle of the leg

When the leg is flexed, the area is felt as a deep hollow space; but when the leg is extended, the contents of the fossa are pushed backwards by the articulated bones of the knee joint, thus they become a compact mass, slightly projecting posteriorly.

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Superficial structures on the fossa Terminal part of the “short saphenous

vein” which commences at the lateral border of the foot formed by the confluence of superficial veins. It ascends behind the lateral malleolus, gradually assuming a middle course along the back of the leg up to the popliteal area where it penetrates the popliteal fascia to drain into the popliteal vein.

Sural Nerve - slender sensory - coursing superficially alongside the short saphenous vein; distributing cutaneous branches along the way down to the lateral border of the foot.

The deep fascia is termed “popliteal fascia” which covers the structures in the fossa, reinforced by fascia lata.

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Contents of the Fossa

Posterior Tibial Nerve - occupies the middle of the fossa where it gives off these branches:– Sural nerve.– Motor branches to the heads of the “Triceps Surae” muscles and

“Popliteus muscle of the leg. Common Peroneal Nerve

Popliteal Vein - lies directly anterior [deep] to the tibial nerve. It is formed at the inferior angle of the fossa by the union of the anterior and posterior tibial veins. It continues as the femoral vein after passing through the adductor (hiatus) opening. In the fossa, it receives the short saphenous vein and the genicular veins that accompany the genicular branches of the popliteal artery.

Popliteal Artery - commences at the hiatus tendineus where it lies deep and medial to the vein, gradually crossing over to the lateral side until it terminates in the posterior compartment of the leg by giving anterior and posterior tibial branches.

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Popliteal Artery

Deep in the fossa, it gives off:1. A pair of “superior genicular arteries” - medial and

lateral. 2. A pair of “inferior genicular arteries” - medial and

lateral. 3. A single “middle genicular artery” - that arises from

its anterior surface.

These genicular branches pursue a deep circumferential course around the knee joint to anastomose freely with one another, and also with the descending genicular branch of the femoral and “recurrent branches” from the tibial artery.

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The floor or anterior wall of the popliteal fossa is composed of:

At the upper part, the triangular popliteal surface of the femur covered by periosteum, popliteal fascia and internal ligaments of the knee joint.

At the middle part, the posterior part of the capsule of the knee joint, reinforced by the oblique ligamentous extension of the tendon of the semimembranosus muscle.

Distally, the popliteus muscle with its covering fascia. This muscle is categorized as a deep muscle of the posterior compartment of the leg.