Topic IV - Ant Pelvis and Thigh

gluteal folds

gluteal folds

butt cheek to posterior thigh

perianal

around the anus

perineum

between the anus and the scrotum or the anus and the vulva

contents of femoral triangle

NAVL = from lateral to medial
*Femoral Nerve
*Femoral Artery
*Femoral Vein
*Lymph

boundaries of femoral triangle

base = inguinal ligament

lateral border = sartorius

medial border = adductor longus

boundaries of popliteal fossa (diamond-shaped)

superior border = biceps femoris (lateral side), semitendinosus, and semimembranosus

inferior border = medial and lateral heads of gastrocnemius

contents of popliteal fossa

popliteal artery
popliteal vein
tibial nerve

patella

knee

largest sesamoid bone in the body

joints of the knee

femur and tibia = modified hinge synovial

femur and patella = plane synovial (gliding)

proximal tibia and fibula = plane synovial (gliding)

joints of the ankle

distal tibia and fibula = fibrous (syndesmosis) bound tightly to give ankle stability

tibia/fibula and talus = hinge, uniaxial synovial joint

joints of the foot

intertarsal and tarsal-metatarsal = plane synovial joints

metatarsal-phalanges (MTP) = condyloid synovial joints

interphalangeal (IP) = hinge synovial joint
*the great toe only has a DIP, but the others have a PIP and DIP

three bones of the inominate

ilium
ischium
pubis

bony landmarks of the ilium

gluteal lines
ala (wing)
ASIS
AIIS
PSIS
PIIS
Auricular surface (where the sacrum articulates)

bony landmarks of the pubic bone

pubic symphysis
superior pubic ramus
inferior pubic ramus
pectin pubis/pectineal line (ridge where adductor muscles attach)
pubic tubercle
part of obturator foramen

pubic symphysis

Joins right and left inominates

Midline, amphiarthrotic joint covered with hyaline cartilage

Has a disc

Has ligaments

Rotation and translation movements

Completes the pelvic ring

Provides stress relief to the pelvis in walking
*and in childbirth

bony landmarks of the ischium

ichial tuberosity (sit bones)
greater sciatic notch
ischial spine
lesser sciatic notch
acetabulum
obturator foramen

posterior ligaments

sacrospinous ligament
sacrotuberous ligament
sacroiliac ligament
iliolumbar ligament

anterior ligaments

iliofemoral ligament
pubofemoral ligament
ischiofemoral ligament

sacrospinous ligament

from sacrum to ischial spine of inominate

through greater sciatic notch

sacrotuberous ligament

from sacrum to ischial tuberosity

through lesser sciatic notch

sacroiliac ligament

from sacrum to inominate

strengthens articulation for the transfer of weight

interosseous posterior and anterior ligaments that make up the sacroiliac ligament

iliolumbar ligament

between transverse processes of L5 to inominate

helps strengthen joint between S1 and L5

iliofemoral ligament

upside down "Y"

AKA ligament of bigelow

STRONGEST LIGAMENT RESISTING HYPEREXTENSION

from AIIS to acetabular ring and intertrochanteric line

pubofemoral ligament

from femur to pubic bone

PREVENTS HYPERABDUCTION and HYPEREXTENSION

ischiofemoral ligament

ischial portion of acetabular ring and femoral neck

WEAKEST OF THE THREE LIGAMENTS - prevents hyperextension

tightens with hyperextension and relaxes with flexion

femur

largest, longest, strongest, heaviest bone in the body

carries a great load - between 13-300% of the body weight is transmitted through the femoral head to the acetabulum and then directed toward the SI joint and the pubic symphysis

head of femur

sits in acetabulum

articulates with lunate surface (horseshoe shaped surface on the inner aspect of the acetabulum)

fovea of the head of the femur

dimple in the central area of the head of the femur

attachment site for the ligamentum teres (no structural support - there to transmit a branch of the obturator artery which will help supply some blood)

neck of the femur

connects the head to the shaft

displaces the shaft away from the hip joint

shaft of the femur

Courses in medial direction (inwardly)

Places the knees more midline than the hip

Femur bends with body weight

Trabecular pattern to the bone which allows for flexibility, bending

Stress is dissipated through compression along the shaft which increases weight bearing and load capacities

greater trochanter of the femur

Lateral and superior; large - can be seen on anterior and posterior sides of the femur

Lots of muscles attach here: piriformis, etc.

lesser trochanter of the femur

medial and inferior

attachment site for iliopsoas and adductor brevis

intertrochanteric line of femur

Runs between greater and lesser trochanters on anterior side

Site of attachment for ligament - ligament of bigelow (y ligament)

linea aspera of femur

Runs all the way up the posterior side of the femur

There's a medial lip and lateral lip to the linea aspera

Attachment site for muscles - quads
Lateral lip of linea aspera = vastus lateralis
Medial lip of linea aspera = vastus medialis

pectineal line of femur

Medially

Just below the lesser trochanter on the posterior side

Attachment for pectineus muscle

intertrochanteric crest of femur

Posterior surface running between lesser and greater trochanters

Quadrate tubercle - mark on the crest where quadratus femoris attaches

adductor tubercle of femur

Medial aspect

Superior part of epicondyle and inferior part of supraconylar ridge

Attachment site for adductor magnus - hamstring portion

bony landmarks of the tibia

Tibial tuberosity
-Anterior projection just below the tibial plateau
-Attachment site for quadriceps muscles

Medial malleolus
-More superiorly positioned than fibula

Facet for the head of the fibula

Lateral condyle

Medial condyle

Plateaus
-Get a roll and slide and glide at this joint with the femur
-Not a well-defined fossa = unstable knee joint

Intercondyloid eminence = ligamentous attachment sites

Osgood-Schlatter's Disease

AKA tibial tubercle apophysitis

Enlargement of bony area from micro-trauma in youth (running and jumping)

overuse of quads

treatment is stopping running and jumping, kneeling, etc.

patella alta

Patella lies proximal in relationship to trochlea in patellar groove

PATELLA RIDING HIGH IN PATELLAR GROOVE = PATELLA ALTA

AKA attenuating patella

Very rare

Can affect mobility and leg strength

Usually smaller patella

Associated issues:
-Retro-patellar pain (behind the patella)
-Dislocations
-Chondromalacia (softening of posterior surface) - AKA runner's knee
-Swelling at knee joint

patella baja

Patella lies distal in the trochlea in patellar groove

PATELLA RIDING LOW IN PATELLAR GROOVE = PATELLA BAJA

Associated issues:
-restrictive range of motion
-grinding, crepitation
-retro-patellar pain (behind the patella)
-Can lead to significant mobility issues or dysfunction with the quads
-Fractures
-Ligaments - especially ACL

lumbar plexus

DRAW THIS

lumbar vertebrae 1-4

line straight out from each

arrow head or 'carrot' out from each line

'carrot' bridge from L1-L2 and L2-L3

waterfalls -
tops of Ys from L2-L4 join together
bottoms of Ys for L2-L4 join together

order of nerves off the lumbar plexus

IH - iliohypogastric
ii - ilioinguinal
GF - genitofemoral
LFC - lateral femoral cutaneous
F - femoral (L2-L4)
O - obturator (L2-L4)

IH - iliohypogastric

Motor: responsible for TA and obliques

Sensory: skin to lateral gluteal area

ii - ilioinguinal

Motor: IO, TA

Sensory: genitalia

GF - genitofemoral

Motor: genitals

Sensory: upper medial thigh

LFC - lateral femoral cutaneous

Sensory: lateral aspect of thigh

F - femoral

Motor: quads, sartorius, pectineus, iliacus

Sensory: skin of anterior thigh

*in the femoral triangle

O - obturator

Motor: adductors that have the word adductor in them (adductor longus, adductor brevis, adductor magnus - adductor portion), obturator externus

Sensory: skin to medial thigh

sacral plexus

DRAW THIS

lumbar vertebrae 4-5, S1-S4

step 1: write blocks of vertebrae with numbers going down the side 3, 4, 5, 5, 3, 1 on the right

step 2: write all nerves down the left side

step 3: waterfalls following
3, 4, 5, 5, 3, 1 = the amount of waterfalls coming off of each

L4 (3), L5 (4), S1(5) all start at the top with Sup G

S2 (5) starts with CF down to Pudendal

**ODDBALL: S3 (3) starts with tibial, (skips INF G), contributes to PFC and pudendal

S4 (1) goes to pudendal

sacral plexus order of nerves

SUP G - superior gluteal
CF - common fibular (or common peroneal)
T - tibial
INF G - inferior gluteal
PFC - posterior femoral cutaneous
Pudendal

superior gluteal (SUP G)

Motor: TFL, gluteus medius, gluteus minimus

common fibular (CF)

Motor: muscles of lateral compartment of leg, tibialis anterior and toe extensors

tibial (T)

Motor: muscles of posterior compartment of leg, some foot muscles

inferior gluteal (INF G)

ONLY JOB = gluteus maximus

posterior femoral cutaneous (PFC)

Sensory: skin of butt

pudendal

Motor: genitalia, levator ani muscles of the pelvic floor

*has to do with urinary and fecal continence in the body

which nerve has the most contributions from the sacral plexus?

TIBIAL NERVE (L4, L5, S1, S2, S3)

which nerve has contributions from S2-S4?

PUDENDAL

trace arteries from aorta down to leg

Aorta --> right/left common iliac artery --> right/left external iliac artery --> as soon as this crosses under inguinal ligament it becomes right/left femoral artery --> deep femoral artery and femoral artery --> femoral artery branches into medial and lateral circumflex femoral arteries which circle around the neck of the femur --> femoral artery goes down and passes through the adductor hiatus from anterior to posterior behind the knee and becomes --> popliteal artery --> geniculares vessel (supply blood to the knee) and anterior tibial and posterior tibial arteries which supply all muscles of the leg

common iliac artery --> internal iliac artery --> cranial and caudal gluteals (supply glutes), internal pudendal (supplies perineum, external genitalia), and obturator (supplies adductor muscles)

deep veins

Share the names with the arteries that they travel with --> all going from the foot up to the inferior vena cava (the deoxygenated blood)

Some of those deep veins: tibial, fibular, popliteal, femoral, external and internal iliac, common iliac = all named for region that they're in and match the arterial vessels they travel with

superficial veins

Dorsal venous arch (foot)

Great saphenous (empties into femoral)
-Historically harvested for coronary bypass surgery
-They would turn it inside out because of the valves in veins (arteries don't have valves)
-NOW they use mammary arteries from the posterior surface of the ribcage

Small saphenous (empties into popliteal)

iliacus

proximal attachment: iliac crest, iliac fossa, ala of sacrum, and anterior sacroiliac ligaments

distal attachment: tendon of psoas major, lesser trochanter, and femur distal to it

innervation: femoral nerve

action: acting conjointly in flexing thigh at hip joint and in stabilizing this joint; psoas major is also a postural muscle that helps control deviation of the trunk and is active during standing

psoas major

proximal attachment: sides of T12-L5 vertebrae and discs between them; transverse processes of all lumbar vertebrae

distal attachment: lesser trochanter of femur

innervation: anterior rami of lumbar nerves

action: acting conjointly in flexing thigh at hip joint and in stabilizing this joint; psoas major is also a postural muscle that helps control deviation of the trunk and is active during standing

iliopsoas

iliacus and psoas major join together below the inguinal ligament to form iliopsoas and insert on lesser trochanter of femur

very strong hip flexor; primary flexor of hip; helps stabilize the hip and contributes to a bit of ER

psoas minor

NOT a hip flexor

Shoelace size - really not going to do much of anything

PA: sides ot T12-L1 vertebrae and intervertebral disc

DA: pectineal line

SUPPOSEDLY assists psoas major and flexing the pelvis and lumbar region of vertebral column

tensor fascia lata

proximal attachment: ASIS; anterior part of iliac crest

distal attachment: iliotibial tract, which attaches to lateral condyle of tibia (Gerdy's tubercle)

innervation: superior gluteal nerve

action: flexes thigh

iliotibial tract (IT BAND)

Runs between glute max and TFL

Runs down to Gerdy's Tubercle on tibia

Kinda like the seam on the side of your pants

You will find that when you dissect, this tissue runs all around the leg - encompasses the leg

issues involved with iliopsoas

If you have tightness of the iliopsoas, you can increase the lordosis of the lumbar spine

Vertebrae being pulled anteriorly and inferiorly could create back pain

-People who sit a lot could get tight iliopsoas
-People with low back pain often have tight iliopsoas
-People with above the knee amputation tend to have this

why is it helpful to have connective tissue wrapping around the muscles of the thigh?

VENOUS RETURN

what effect can tightness of the IT band have on the patella?

could pull the patella laterally and create a lateral tracking problem sometimes leading to dislocation

sartorius

proximal attachment: ASIS and superior part of notch inferior to it

distal attachment: superior part of medial surface of tibia (PES ANSERINE)

innervation: femoral nerve

action: flexes, abducts, and laterally rotates thigh at hip joint; flexes leg at knee joint

pes anserine

Located on medial superior tibia

Mnemonic for who attaches there: "Say grace at supper time"

Sartorius
Gracilis
Semitendinosus

Bursa here that gets inflamed sometimes, especially with runners

quadriceps femoris

vastus lateralis
vastus intermedius
rectus femoris
vastus medialis

vastus lateralis

proximal attachment: greater trochanter and lateral lip of linea aspera

distal attachment: via common tendinous (quadriceps tendon) and independent attachments to base of patella; indirectly via patellar ligament to tibial tuberosity; also attaches to tibia and patella via aponeuroses (medial and lateral patella retinacula)

innervation: femoral nerve

action: extends leg at knee joint

vastus intermedius

proximal attachment: anterior and lateral surfaces of shaft of femur

distal attachment: via common tendinous (quadriceps tendon) and independent attachments to base of patella; indirectly via patellar ligament to tibial tuberosity

innervation: femoral nerve

action: extends leg at knee joint

rectus femoris

**EXCEPTION TO QUAD MUSCLES: can also be a hip flexor since it attaches at AIIS

proximal attachment: AIIS and ilium superior to acetabulum

distal attachment: via common tendinous (quadriceps tendon) and independent attachments to base of patella; indirectly via patellar ligament to tibial tuberosity

innervation: femoral nerve

action: extends leg at knee joint; rectus femoris also steadies hip joint and helps iliopsoas flex thigh

vastus medialis

proximal attachment: intertrochanteric line and medial lip of linea aspera of femur

distal attachment: via common tendinous (quadriceps tendon) and independent attachments to base of patella; indirectly via patellar ligament to tibial tuberosity; also attaches to tibia and patella via aponeuroses (medial and lateral patella retinacula)

innervation: femoral nerve

action: extends leg at knee joint

what is the innervation of all quad muscles?

femoral nerve

what is a common action of all quad muscles?

extend the leg at the knee

pectineus

proximal attachment: superior ramus of pubis

distal attachment: pectineal line of femur, just inferior to lesser trochanter

innervation: femoral nerve

action: adducts and flexes thigh; assists with medial rotation of thigh

adductor longus

proximal attachment: body of pubis inferior to pubic crest

distal attachment: middle third of linea aspera of femur

innervation: obturator nerve

action: adducts thigh

adductor brevis

proximal attachment: body and inferior ramus of pubis

distal attachment: pectineal line and proximal part of linea aspera of femur

innervation: obturator nerve

action: adducts thigh and to some extent flexes it

gracilis

proximal attachment: body and inferior ramus of pubis

distal attachment: superior part of medial surface of tibia (PES ANSERINE)

innervation: obturator nerve

action: adducts thigh; flexes leg, and helps rotate it medially

adductor magnus (hamstring portion)

proximal attachment: ischial tuberosity

distal attachment: adductor tubercle of femur

innervation: tibial part of sciatic nerve

action: adducts thigh; extends thigh

adductor magnus (adductor portion)

proximal attachment: inferior ramus of pubis, ramus of ischium

distal attachment: gluteal tuberosity, linea aspera, medial supracondylar line

innervation: obturator nerve

action: adducts thigh; flexes thigh

obturator externus

proximal attachment: margins of obturator foramen and obturator membrane

distal attachment: trochanteric fossa of femur

innervation: obturator nerve

action: laterally rotates thigh; steadies head of femur in acetabulum

adductor canal

Channel through the muscles in the medial anterior thigh with adductor magnus being posterior part of it

Channel getting vessels ready to go through the hiatus

Start = apex of femoral triangle

Finish = adductor hiatus

Contents = femoral artery and vein

which ligament is the STRONGEST ligament resisting hyperextension?

iliofemoral ligament

which ligament strengthens the articulation for the transfer of weight?

sacroiliac ligaments

which ligament limits hyperABDuction and also limits hyperextension?

pubofemoral

what travels through the greater sciatic notch ABOVE the piriformis muscle?

superior gluteal nerve
superior gluteal artery
piriformis muscle

what travels through the greater sciatic notch BELOW the piriformis muscle?

(POPS IQ):
Pudendal nerve
Nerve to Obturator internus
Posterior femoral cutaneous nerve
Sciatic nerve
Inferior gluteal nerve and artery
Nerve to Quadratus femoris

What is the condition called that affects children experiencing growth spurts and usually occurs in children playing sports that involve running and jumping?

Osgood Schlatter Disease

How do you treat Osgood Schlatter Disease?

Stop running and jumping

It will usually go away with time and rest

what muscles are innervated by the femoral nerve?

ALL of the Quad Muscles
Sartorius
Pectineus
Iliacus
Also, sensory to skin of anterior thigh

What muscle group is innervated by the Obturator nerve?

Adductors:
Adductor longus
Adductor brevis
Adductor magnus
Also, obturator externus, gracilis, and some of the skin of the medial thigh

What adductor muscle is the exception and is innervated by femoral nerve?

PECTINEUS

What is the muscle group innervated by the Sciatic Nerve?

hamstrings

The Sciatic Nerve splits into what nerves, and what are a couple muscles innervated by those nerves?

TIBIAL NERVE:
Posterior Leg
Calves
Foot

COMMON FIBULAR (PERONEAL) NERVE:
Tibialis Anterior
Toe Extensors