GLUTEAL REGION pdf - MUNTADHAR ALWAAILI

o The primary function of the lower limb

is to

support the weight of the body

to provide a stable foundation in
standing, walking & running.

o They have become specialized for

locomotion

o The lower limbs although similar in

structure in many aspect to the upper
limbs ,have

less freedom of movement.

o Where as the pectoral girdle of the

upper limb is united to the trunk by
only a small joint ,

the sternoclavicular

joint

, the two hip bones articulate

posteriorly with the trunk at

the strong sacroiliac joint & anteriorly

with each other at the symphysis pubis.

is that the lower limbs are

more

stable

can bear the weight of the body

during standing ,walking&running.



Gluteal region



Thigh



Knee



Leg



ankle



Foot

o Lies behind thepelvis , is bounded

superiorly by the iliac crest

inferiorly by the fold of the buttock.

o It is largely made up of the

gluteal muscles

and a

thick layer of

superficial fascia

which overlies the (muscles ,nerves & vessels)

which leaving the inside of the pelvis and passing to the lower limb.

o The

panniculus adiposus

is well developed in the gluteal region and

gives to the buttock its characteristic convexity.

o The

fold of the buttock

is the transverse skin crease for the

hip joint

& is not caused by the oblique lower border of the gluteus m.

o The blood supply of the skin & fat

: is derived from perforating

branches of the

superior & inferior gluteal arteries.

o Lymphatic driange : drain into

lat.group of the superficial inguinal

lymph node

o are derived from

posterior & anterior rami

of spinal nerves as

follow:

Upper medial quadrant Post.rami of :

upper 3 lumbar Ns
upper 3 sacral Ns.

Lower medial quadrant post cut. N. of the thigh (S1,2,3 ant.rami)

Upper lateral quadrant lat.brach of iliohypogastric L1,T12

N.ant.rami.

Lower lateral quadrant lat. Cut. N. of the thigh. (L2,3 ant.rami)

The skin over the coccyx
in the floor of the natal
cleft

is supplied by small branches of the lower
Sacral & Coccygeal nerves.

o Is continuous below with the

deep fascia or fascia lata of the thigh.

o In the gluteal region it

split

to enclose the

gluteus maximus m

o Above it continues as a

single layer

that cover the outer surface of

the

glut.med.

and is attached to the iliac crest.

o On the lat.surface of the thigh the fascia is thickened to form a

strong wide band the

iliotibial tract

o This is attached above to the tubercle of the

iliac crest

and below to

the

lateral condyle of the tibia

o The iliotibial tract form a sheath for the

tensor fascia lata m.

and

receive the

greater part of insertion of the gluteus maximus

1- Gluteus maximus.
2- Gluteus medius.
3- Gluteus minimus.
4- Tensor fasciae latae.
5- (Short) lateral rotaters of the thigh at the hip joint



Piriformis



Gemellus superior



Gemellus inferior



Obturator internus



Quadratus femoris

o Is the most superficial of the group.
o It is a large flat quadrilateral forming the prominence of the

buttock.

From an extensive area including :



the gluteal surface of the ilium behind the posterior gluteal line



the post. surface of the sacrum , coccyx & sacrotuberous ligament.

The fibers pass downward & laterally into the

iliotibial tract 3/4

and

the

gluteal tuberosity of the femur 1/4

Inferior gluteal n.

1- it is a

powerful lateral rotater & extensor

of the hip joint.

2- acting through the iliotibial tract it

extend & stabilize the knee joint

from the

outer edge of the iliac crest

between the ant.sup.iliac

spine & the iliac tubercle.

to the iliotibial tract.

: sup.gluteal n.

: extent & stabilise the knee joint.

gluteal surface of the ilium

between

middle & post.

gluteal line.

lateral surface of greater trochanter.

gluteal surface of the ilium

between

middle & inferior

gluteal line.

anterior border of the greater

trochanter.

sup.gluteal n.

o powerful abductors at the hip joint
o weak medial rotators at the hip.

o The muscles contract and steady the pelvis on the lower limb.

o When the foot of the opposite side is taken off the ground and

thrust foreword , the pelvis is held in position and does not tilt
downward on the unsupported side.

The gluteus maximus lies behind the hip joint and overlies ; gluteal
muscles , short lateral rotaters of the hip and structures that passed
through the greater and lesser sciatic foramen.

o is produced by the

sacro-spinous lig.

bridging the greater sciatic

notch in the hip bone.

o The foramen is the

only conduit between

the pelvic cavity and the

buttock.

o Number of structures emerge from the pelvis in to the gluteal

region above or below the piriformis muscle in the greater sciatic
foramen.

o The greater sciatic foramen is a major

foramen

of the

pelvis

It is bounded as follows:

Anterolaterally the

greater sciatic notch

of the

illium

Posteromedially the

sacrotuberous ligament

Inferiorly

the

sacrospinous ligament

and the

ischial spine

Superiorly

the

anterior sacroilliac ligament.

o It is partially filled up , by the

Piriformis

which leaves the pelvis

through it.

o The following structures make their exit from the pelvis through

the greater sciatic foramen.

o pass upward and lateraly between

gluteus medius & minimus

o supplying these

muscles and tensor fascia lata.

o The artery takes part in the anastomosis around the hip.
o It is branch of internal iliac artery.

o It is the largest nerve in the body (L4,5.S1,2,3) .
o emerge

lateral

to the ischial spine and lies successively on



the root of the ischial spine ,



superior gemellus m. ,



obturater intrenus m. ,



inferior gemellus m. ,



quadratusfemoris m.

o To reach the back of the

adductor magnus.

o It is related posteriorly to the

post.cut.n.

of the thigh and the

gluteus maximus.

o It lies about mid-way between the ischial tuberosity and the

greater trochanter.

o It leaves the buttock region by

passing deep to the long head of

the biceps femoris

to enter the back of the thigh.

The sciatic n.gives no branches

in the gluteal region.

The nerve is sometimes injured by :

o  penetrating wounds pelvis
o  dislocation of the hip joint
o  badly placed intramuscular injection in the gluteal region

The injection should be placed in the

upper outer quadrant

the buttock

After a short course enter the

substance of gluteus maximus.

o Ramifies in the lower part of the buttock and take part in an

anastomosis around the hip joint.

o It is branch of internal iliac A.

o They cross the ischial spine and immediately re-enter the pelvis

through the lesser sciatic foramen , they then lie in the
ischiorectal fossa.



the pudendal N. supplies stractures in the perineum.



The N.to the obturater internus supplies the obturater internus
m.on its pelvic surface.

o A branch of the sacral plexus cross the root of the ischial spine

deep to the sciatic N.and the tendon of obturater internus .

o It supply qudratus femoris and inferior gemellus.

o Emerge superficial to the sciatic n.and descend in the midline of

the thigh beneath the deep fascia.

o it supplies the skin of the buttock , perineum and post.aspect of

the thigh.

o An opening between the

pelvis

and the posterior thigh

o Lies between

Sacrotuberous and Sacrospinous ligament

o Is bounded

lateraly

by the

concave part of the ischium

that lies

between the ischial spine and ischial tuberosity.

o The

obturator internus m.

as it emerges from the

lateral wall

of the

pelvis, plugs the lateral part of the foramen.

o The

medial part

of the foramen form a

tunnel shaped orfice

which

leads foreward into

pudendal canal.

o The

internal pudendal vessels and nerve

enter the foramen from

the buttock and directed into the canal.

The lesser sciatic foramen has the following boundaries:

Anterior:

the

tuberosity of the ischium

Posterior:

the

sacrotuberous ligament

Superior:

the

spine of the ischium

and

sacrospinous ligament

laterally:

the concave part

of the ischium that lies between the

ischial spine and ischial tuberosity

It transmits the following structures:

o the tendon of the Obturator

internus

o internal pudendal

artery

o  internal pudendal vein
o  pudendal nerve
o  nerve to the obturator internus

from the ant. Surface of the 2

and 4

Sacral vertebrae

within the pelvis.

the fibers pass downward and laterally through the

greater

sciatic foramen

and are attached to the

upper border of the

greater trochanter.

ant. Rami of the 1

and 2

Sacral nerves.

spine of the ischium.

n.to the obturater internus.

upper margin of the ischial tuberosity

with the tendon of the obturater internus.

N.to the quadratus femoris from sacral plexus.

from the pelvic surface of the obturater membrane and the

surrounding bones.

the tendon pass through the lesser sciatic foramen and is

joined by the tendon of sup.& inf.gemelli.The common
tendon is inserted into the upper border of the greater
trochanter.

from the lateral border of the ischial tuberosity.

quadrate tubercle on the intertrochanteric crest of the

femur.

o Is a synovial joint of the ball and socket variety between the

acetabulum of the hip bone and the head of the femur.

o The articular surface of the acetabulum is inverted u shaped being

deficient inferiorly at the acetabular notch.

o The acetabulum is cupped and depened by the acetabular labrum, a

rim of fibrocartilage attached to its borders .

o bridging the acetabular notch is the transverse acetabular ligament.

o strong and dense, attached :



proximally

to the acetabular labrum and the edge of the

notch.



distally

it is attached to the femur along the intertrochanteric

line infront and to the neck 1 cm above the intertrochanteric
crest from behind.

o some of the capsular fibres turn back medially along the neck and

are known as retincula,they carry blood vessels toward the head

is a strong inverted v shaped attached above to the A.I.I.S. and
bifuricating inferiorly gain attachment to each end of the
intertroghanteric line.

passes from iliopubic eminence to the lower part of the capsule and
under surface of the neck.

passes upward from the acetabular margin to the upper end of the
intertroghanteric line and the adjacent upper surface of the neck.

The three ligaments are spiral in such away as to limit extension at the
joint.

passes from the fovea to the articular notch .it is lax may contain some
vessel of special importance in the child.

o the synovial membrane lines the nonarticular surface of the joint

and ensheath the ligamentum teres.

o The cavity of the joint communicate with the psoas bursa between

the iliofemoraland pubofemoral lig.

The hip joint is capable of :

flexion , extension , abduction , adduction , circumduction , medial and
lateral rotation.

o In the anatomical position the line of weight passes behind the axis

of the joint and so gravity encourage extension of the joint.

iliopsoas , assisted by tensor fascia lata,rectus femoris , Sartorius ,
pectineus.

the movement is limited to about

90 degree

when the knee is flexed

and is much less when the knee is extended because of

tension in the

hamstring muscles

gluteus maximus , assisted by gravity , hamstringand tensor fascia lata.

limited by 3 capsular thickening.

gluteus medius and minimus.

adductor ms. Of the thigh , gracilis and gravity.

Occur around an axis joining the center of the head of the femor to the
intercondylar notch of the femur.

ant fibres of gluteus medius and minimus assisted by the iliopsoas.

Short lateral rotaters assisted by glut.maximus

In spite of its great mobility it is very stable because :

1- deep cup of the acetabular clasping the femoral head.
2- strong capsule and its thickening particularly iliofemoral lig.
3- large no. of closely applied short articular muscles.

Branches of femoral,obturater and sciatic n.

o Three associated with glut.maximus

1- between tendon of insertion and the greater trochanter.
2- between tendon of insertion and vast.lateralis.
3- overlying the ischial tuberosity

o Psoas bursa



separate the iliopsoas tendon from the iliac fossa and
supr.pubic ramus.



it may communicate with the cavity of the hip joint between
the iliofemoral and pubofemoral lig.

iliopsoas,pectineus separate the joint from the femoral vessels

and nerve.

piriformis,obturater internus,quadratus femoris separate the

joint from the sciatic n. and gluteus maximus.

gluteus minimus and reflected head of rectus femoris

obturator externus.

The

capsule

and

synovial membrane

are supllied from nearby

vessels.

The

head

and

intracapsular part of the neck

receive their blood

supply from two sources.

1-The

ligament of the head

contains an arterial twig from the

obturater artery

,this vessel supplies the head in the young

bone. As age advanced it will supply only thin flake of bone.

2-The

major

part of the head is supplied by

arteries in the

retincula

which bind down the nuterient arteries that pass

chiefly from the

trochanteric anastomosis

along the neck of the

femur.

Fracture of the femoral neck within the capsular attachment
necessarily rupture the

retincular fibers

and the

vessels

causing

avascular necrosis of the head.

This provides the main source of blood supply of the head of the
femur. It lies near the

trochanteric fossa

. It is formed by anastomosis

of :

1- descending branch of sup. gluteal A.
2- ascending branches of both lat. and med. femoral circumflex As.
3- inferior gluteal A.

Branches from the anastomosis pass along the femoral neck beneath
the retincular fibres of the capsule.

Is situated at the level of the

lesser trochanter

of the femur.

Together with the trochanteric anastomosis provide a connection
between

internal iliac and femoral arteries

It is formed by

anastomosis of :

1- Inf. gluteal A.
2- Transverse branch of medial circumflex A.
3- Lateral femoral circumflex A.
4- The first perforating artery –a branch of the profunda femoris A.