Hip and Gluteal Region

Which bones make up the hip bone?

Fusion of ilium, ischium, and pubis (fused by 15-17, complete by 23)

Label 1

Femoral head

Label 3

Fovea capitis

Label 5

Trochanteric fossa

Label 7

Greater trochanter

Label 9

Neck

Label 11

Intertrochanteric line

Label 12

Intertrochanteric crest

Label 13

Lesser tubercle

Label 15

Pectineal line

Label 16

Gluteal tuberosity

Label 17

Linea aspera

Label 18

Medial supracondylar ridge

Label 19

Lateral supracondylar ridge

Label 20

Popliteal surface

Label 22

Medial epicondyle

Label 24

Lateral epicondyle

Label 25

Patellar surface

Label 26

Intercondylar fossa

Label 27

Lateral condyle

Label 28

Medial condyle

Label 29

Adductor tubercle

Label 31

Popliteal groove

Is this a left or right femur and why?

Right; the femoral head will face the body, and the condyles will face the back

What are the muscles of the gluteal region?

Gluteus maximus, gluteus medius, gluteus minimus, tensor fascia latae (TFL)

What are the attachments of the gluteus maximus?

Ilium posterior to posterior gluteal line; dorsal surface sacrum/coccyx, sarcotuberous ligament to gluteal tuberosity

MOST end in iliotibial tract which inserts on lateral condyle of tibia

What is the action of the gluteus maximus?

Extends thigh (especially form flexion), assists with lateral rotation; steading thigh, assists in rising from sitting position

What innervates the gluteus maximus?

Inferior gluteal nerve L5, S1/2

Where is a gluteofemoral bursa?

Between IT tract and proximal attachment of vastus lateralis

What is trochanteric bursitis?

Painful inflammation of the bursa located b/w glute max & greater trochanter on the outer side of the hip from high stepping activities

What is weaver’s bursitis?

Painful inflammation of the fluid-filled sac located b/w glute max and ischial tuberosity at the bottom of the pelvis caused by biking, rowing, weaving, other sitting activities

What are the attachments of the gluteus medius?

External surface of ilium b/w anterior and posterior gluteal lines to lateral surface GT of femur

What is the action of the gluteus medius?

Abduct and medially rotate thigh; keep pelvis level when ipsilateral limb is weight bearing

What innervates the gluteus medius?

Superior gluteal nerve L4/5, S1

What are the attachments of the gluteus minimis?

External surface of ilium b/w anterior and inferior gluteal line to anterior surface of GT

What is the action of the gluteus minimis?

Abduct and medially rotate thigh; keep pelvis level when ipsilateral limb is weight bearing

What innervates the gluteus minimis?

Superior gluteal nerve L4/5, S1

You have a patient that has pain down the lateral side of thigh and leg but they don’t describe it as a radiating burning, numbness, or tingling sensation. What could be the possible diagnosis?

Referred glute min pain

What is trendelenburg gait?

An abnormal walking pattern where the pelvis drops on one side due to weak hip abductor muscles; weight is shifted to the contralateral/weight bearing side to raise pelvis and allow room for foot clearance

What are potential causes of trendelenburg gait?

Injury to superior gluteal nerve, fracture of GT, and others

What is the trendelenberg test?

Ask the pt to stand on one leg and their pelvis on unsupported side descends indicating glute med weakness on weight bearing side; they shift to opposite side of weakness (?)

What are the attachments of the TFL?

ASIS and anterior part of iliac crest to IT tract which attaches to lateral condyle of tibia

What is the action of the TFL?

Weak abduct and medially rotate thigh; keep pelvis level when ipsilateral limb is weight bearing; can help psoas and rectus femoris with hip flexion

What innervates the TFL?

Superior gluteal nerve L5,S1

How does the TFL work with the glute max?

They have an antagonistic relationship; the TFL counteract the glute max to maintain proper alignment

How does the TFL work with other gluteal muscles?

As a synergist for flexion, abduction, and IR

What are the attachments of the piriformis?

Anterior surface of sacrum, sarcotuberous ligament to superior border of GT of femur

What is the action of the piriformis?

Laterally rotate extended thigh and abducted flexed thigh

What innervates the piriformis?

Nerve to piriformis S1/2

What are the attachments of the obturator internus?

Pelvic surface of obturator membrane and surrounding bones to medial surface of GT (trochanter fossa) of femur

(in between gemelli brothers)

What is the action of the obturator internus?

Lateral rotation of the hip

What innervates the obturator internus?

Nerve to obturator internus L5, S1/2

What are the attachments of the superior and inferior gemelli?

Superior: ischial spine

Inferior: ischial tuberosity

both to to medial surface/posterior aspect of GT

What is the action of the superior and inferior gemelli?

Lateral rotation of the hip

What innervates the superior gemelli?

Nerve to obturator internus L5, S1/2

What innervates the inferior gemelli?

Nerve to quadratus femoris L4/5, S1

What are the attachments of the quadratus femoris?

Lateral border of ischial tuberosity to quadrate tubercle in intertrochanteric crest of femur

What is the action of the quadratus femoris?

Lateral rotation of the hip

What inneravtes the quadratus femoris?

Nerve to quadratus femoris L4/5, S1

What is the triceps coxae?

Tendons of the obturator internus and gemelli brothers blend together to perform the actions and sometimes become hard to differentiate

What supplies the skin on the buttocks?

Cluneal nerves

Where do cluneal nerves arise from?

Superior cluneal: branches of posterior rami of L1-3 from lumbar plexus

Middle & inferior cluneal: posterior rami of sacral segments of sacral plexus

What makes up the sciatic nerve?

Axons from the common fibular and tibial nerve; when they split, the common fibular innervates the lateral fibula and the tibial innervates the posterior tibia regions

What is the path of the superior gluteal nerve?

From sacral plexus, leaves pelvis through a superior part of greater sciatic foramen, superior to piriformis with superior gluteal artery (branch of internal iliac artery), runs horizontal between glut med and min to innervate them along wit the TFL

What is the path of the inferior gluteal nerve?

From sacral plexus, leave pelvis through inferior part of greater sciatic foramen, inferior to piriformis, lies superior to sciatic nerve and accompanies inferior gluteal artery

What is the path of the sciatic nerve

Main branch of sacral plexus; leaves pelvis by traveling through inferior part of greater sciatic foramen; runs deep to glute max; lateral part emerges inferior to piriformis; lateral to posterior femoral cutaneous, inferior gluteal, and pudendal nerves; descends into posterior thigh and midway separates into tibial and common fibular branch superior to popliteal fossa, supplies no structures in gluteal region, supplies posterior thigh muscles

Where would a intramuscular injection of the glueal region be?

RUQ to avoid sciatic nerve; superior to a line from PSIS to superior GT

What are important variations of the sciatic nerve?

In 12% of people the sciatic nerve divides before exiting the greater sciatic foramen

In 0.05% of people, the common fibular division passes superior to the piriformis

What is the path of the posterior femoral cutaneous nerve?

Branches from S2/3; leaves pelvis with inferior gluteal nerve and vessels, and the sciatic nerve; supplies skin on inferior part of buttock, skin of perineum, skin of posterior thigh, and proximal part of leg

What is the path of the pudendal nerve?

Most medial structure to pass through greater sciatic foramen inferior to piriformis muscle; reenters pelvis through lesser sciatic foramen to supply structures in the perineum; provides motor innervation to the levator ani muscles