Week 3-Hips, Glutes, lower limb

Popliteal fossa

Popliteal fossa

Diamond shaped fate filled compartment located at the back of the knee  \n \n Important passageway

contents of popliteal fossa

Popliteal artery and vein \n Tibial nerve \n Common peroneal nerve

Boundaries of popliteal fossa

4 borders \n 1. Upper lateral: biceps femoris \n 2. Upper medial: semimembranosus  \n 3. Lower lateral: gastrocnemius lateral head \n 4. Lower medial: gastrocnemius medial head  \n \n Roof: \n 1. Dense layer of popliteal fossa continues with fascia that covers thigh and leg  \n \n Floor: \n 1. Posterior (popliteal) surface of femur \n 2. Posterior capsule of knee \n 3. Popliteus muscle

What are the most superficial and lateral structures within the popliteal fossa

1. Tibial nerve - travels vertical down through the fossa  \n 2. Common peroneal nerve

The femur

thigh bone

What is the deepest structure in the popliteal fossa

popliteal artery \n \n 1. Lies on popliteal surface of posterior femur

Genicular arteries form genicular anastimosis ???

Branches of the Popliteal Artery providing the blood supply to the area about the knee

Popliteal vein

1. Formed by anterior and posterior tibial veins at lower border of popliteal fossa  \n \n 2. Lies slightly medial to popliteal artery as it ascends from the popliteal fossa —> then becomes superificla to the popliteal artery higher up —> continues to beomce the femoral vein to the level of the adductor hiatus  \n \n 3. Popliteal vein and artery and bound together by a thick fascial sheath

Tibial nerve direction

As it descends it gives off muscles branches to the following muscles  \n \n 1. Gastrocnemius \n 2. Popliteus  \n 3. Soleus

common peroneal nerve direction

More lateral  \n \n Follows medial border of biceps femoris muscle

What is the popliteal artery a continuation of

The femoral artery  \n \n Passes through adductor hiatus and then popliteal fossa and becomes politeal artery  \n \n Descends to lower border of popliteus muscle —> then divides into anterior and posterior tibial arteris

What else does the popliteal artery become

1. Genicular arteries \n \n 2. Muscular branches to adjacent hamstring, gastrocnemius, soleus, and plantaris muscles

The hip joint

1. Coxofemoral joint  \n \n 2. Connection between bony pelvis and lower limb \n \n 3. Formed between head of femur and socket of the acetabulum

Hip joint classification

synovial ball and socket

Strength of the hip joint is provided by

Ball and socket shape of articular surfaces - snug fit \n \n 2. Acetabular labrum - deepens the socket  \n \n 3. Thick fibrous capsule reinforced by 3 strong ligaments  \n \n 4. Strong muscles that surround the joint

Hip joint role

Weight bearing  \n \n 2. Placement of foot in space

Hip joint movements

flexion/extension, abduction/adduction, internal/external rotation

Acetabulum

Forms the socket of the hip joint  \n \n 1. Hollowed out area on the lateral aspect f the hip bone \n \n 2. Formed by ilium, ischium, and pubis  \n \n 3. Faces forwards, downwards, and laterally to recieve head of fem

Acetabular labrum

1. Surrounds the margins of the acetabulum (lunate surface) and transverse ligament of the acetabulum  \n \n 2. Raised ring of fibrocartilage  \n \n 3. Projects outwards to deepen socket of acetabulum  \n \n Ring of cartilage that deepens...

Role of acetabular labrum

1. Increases jont congruence and stability  \n \n 2. Icnreases contact area of femur by 22%  \n \n 3. Increases joint volume by 33%

Lunate surface

The articular surface of the acetabulum \n \n 1. Raised Horse shoe shaped ring \n \n 2. Covered in hyaline cartilage

What bridges the two ends of the lunate surface

Transverse ligament of the acetabulum

Head of femur

1. Ball portion of hip joint  \n \n 2. 3/4 shaped sphere \n \n 3. Covered in articular cartilage  \n \n 4. Fits snugly in the acetabulum

Role of all 3 of the hip ligaments in standing

All 3 ligaments are under tension in normal standing where the centre of gravity falls slightly behind the hip joint —> hip joint is in extension  \n \n 2. Tension in the joint capsule is able to support the body without muscular assistance

What is the strongest ligament in the body

iliofemoral ligament

NERVE and blood supply of hip joint

Arteriole supply to the hip joint:  \n \n 1. Occcurs through a periarticular network of arteries around the joint

Neck of the femur blood supply

Network arises from the medial and lateral circumflex arteries  \n \n - the medial circumflex artery provides majority of the blood supply  \n \n 1. These branches give rise to retinacular arteries that supply the head and neck of the femur

Retinacular arteries

Lie within the neck of the femur  \n \n —> thus often torn —> loss of adequate blood supply to head and neck of femur  \n \n - fractures to this region often require total hip replacement

What is the transverse ligament of the acetabulum

1. Converts the gap between lunate surfaces into a foramen \n \n 2. Fibrous connective tissue  \n \n 3. This creates a passage for the artery to the head of the femur

What are the 3 strong ligaments that externally support the hip joint

extracapsular ligaments  \n Iliofemoral  \n \n Pubofemoral \n \n Ischiofemora

How are the gluteal muscles organized?

Into superficial and deep layers

Acetabular fossa

Also called the notch \n \n 2. A hollowed out area in the middle of the horseshoe articular surface  \n \n 3. Filled with the acetabular fat pad  \n \n 4. Contains the artery to the head of the femur  \n \n 5. Non articular = does not contact the head of the femur

gluteal tuberosity

Located on the back of the femur

Ligament to head of femur

Arises from the acetabular foss and transverse ligament of the acetabulum  \n \n 2. Connects the acetabular foss with the fovea on the head of the femur \n \n 3. Not a true ligament  \n - weak band of connective tissue surrounded by a synovial membrane \n - role is to enlcose artery to the head of the femur \n - not important for stability

Iliofemoral ligament

role:

- reinforces front of fibrous capsule  \n - resists extension of the hip joint  \n Characteristics: "Y" shaped ligaments \n Attachment: \n - attaches from acetabular margins and the inferior iliac spine  \n Insertion: \n - fibres spiral around the front portion of the capsule and insert onto the intertrochanteric line

Artery to the head of the femur

branch of obturator artery (this travels into the acetabular fossa through foramen that is created by the transverse ligament of the acetabulum —> then travels within ligament to the head of the femur)

\n 2. Attaches onto the fovea on the head of the femur  \n \n Role: \n 1. Critical in childhood before closure of growth plate \n 2. Variable in adults and often absent

Fovea to head of femur

Small pit on the top of the head of the femur  \n \n 1. Non articular  \n \n 2. Not covered by hyaline cartilage  \n \n 3. Attachment point for th eligament of the head of the femur

What is the nerve supply of the gluteus maximus

Nerve: inferior gluteal nerve \n \n Nerve roots:  \n L5  \n S1 \n S2

Fibrous capsule

Thick, strong. Extensive  \n \n 2. Attaches medially from the hip bone, just beyond rim of acetabulum  \n \n 3. Attachment: intertronchanteric line on the front of the femur and just before the intertronchanteric crest on the back of the femur

Synovial membrane

Present in all synovial joints  \n 2. Lines inner surface of fibrous capsule  \n 3. Encloses: \n - articular surafces \n - acetabular fossa and fat pad  \n - ligament of the head of the femur  \n - transverse acetabular ligament  \n - neck of the femur

Nerve supply of gluteus medius, Nerve supply of gluteus minimus

superior gluteal nerve \n \n Nerve roots:  \n L4 \n L5 \n S1

Iliofemoral ligament

Role:  \n - reinforces front of fibrous capsule  \n - resists extension of the hip joint  \n Characteristics: "Y" shaped ligaments \n Attachment: \n - attaches from acetabular margins and the inferior iliac spine  \n Insertion: \n - fibres spiral around the front portion of the capsule and insert onto the intertrochanteric line

Actions of gluteus medius and minimus

Anterior fibres also help with internal hip rotation \n Main hip abductors  \n Important for stbailizing pelvis when weigh tbearing on one leg along with tensor fascia lata

Pubofemoral ligament

Location: \n - inferior to the iliofemoral ligament  \n Origin:  \n - obturator crest of pubic bone  \n Insertion \n - runs laterally and downwards to blend with the fibrous capsule of th ehip joint  \n Role: \n - resists hip abduction \n - fibres also tighten in extension

Ischiofemoral ligament

Location:  \n - posterior side of the hip joint  \n Origin: \n - attaches from ischium just medial from the rim of the acetabulum \n Insertion: \n - fibres spiral upwards and laterally to wrap around the femoral neck  \n - attaches onto the base of the greater trochanter deep \n Role: \n - resists hip medial rotation \n - fibres tighten in extension

What are the main abductors of the hip

gluteus medius and minimus

What is the periarticular network made of

1. Lateral and medial circumflex arteries \n 2. Obturator artery \n 3. Superior and inferior gluteal arteries

Tensor fascia lata

Location: \n Anterior lateral aspect of the hip  \n - anterior to hip joint \n Origin: \n - anterior iliac crest \n - anterior superior iliac spine  \n Insertion: \n - iliotibial band  \n Action: \n - works with gluteal muscles to help abduct the hip \n - also tightens the iliotibial band to stabilize the lateral side of knee joint

Nerve supply of the tensor fascia lata muscle

superior gluteal nerve \n Nerve roots: \n L4 \n L5 \n S1

Nerve supply of the hip joint

1. The nerves that supply the hip joint also supply those that surround the muscles of the joint  \n Include: \n 1. Femoral nerve in the front \n 2. Obturator nerve inferiorly  \n 3. Superior gluteal nerve superiorly  \n 4. Nerve to quadratus femoris posteriorly

Iliotibial band

runs superficially down lateral side of thigh to the knee

Gluteal region.

Location: \n Located on the posterolateral pelvis  \n - between the iliac crests to the gluteal folds  \n Transition between the trunk and the lower extremity, but is considered part of the lower extremity

What muscles are important for keeping pelvis level during walking

Gluteus medius, minimus, and tensor fascia lata

What are the superficial muscles of the gluteal region

gluteus maximus, gluteus medius, gluteus minimus, tensor fascia lata

Gluteus maximus

Largest and most superficial of the gluteal muscles  \n Location: \n - all fibres are located posterior to the hip joint  \n - run in inferior and lateral direction  \n Origin: \n - posterior ilium, posterolateral aspect of the sacrum, sacrotuberous ligament \n Insertion: \n Posterior iliotibial band = 75% of fibres \n gluteal tuberosity = 25% of fibres

What muscles help with lateral rotation

Deep gluteal musclces and the gluteus maximus

Gluteal surface of ilium

the broad, flattened area above the acetabulum on the posterolateral aspect of the wing of the ilium

Nerve supply of piriformis

Branches of anterior rami S1 and S2 \n Nerve roots: \n S1 \n S2

Gluteus medius

Origin: \n - gluteal (external) surface of the ilium between the anterior and posterior gluteal lines of the ilium  \n Insertion: \n - inserts via a broad tendon \n - postero lateral aspect of greater trochanter in the area called the elongate facet  \n - lateral (elongate) surface of greater trochanter  \n Fibres: \n - orientated in 3 directions  \n 1. Anterior fibres - located anterior to greater trochanter - travel posterior and inferiorly  \n 2. Vertical fibres - located above the greater trochanter - travel vertically  \n 3. Posterior fibres - located behind the greater trochanter - travel anteriorly and inferiorly  \n Action: \n - hip abduction and internal rotation \n - walking: muscles on stance leg help keep pelvis level

What is the action of the gluteus maximus

1. Powerful hip extensor, especialy when from a flexed position  \n 2. Not active during normal walking  \n 3. Helps with lateral rotation, especially when extending the hip at the same time  \n 4. High when walking on incline with the hips flexed \n 4.4 high during running and jogging with maximum activity on heel strike  \n 5. Resists flexion and internal rotation of hip by extending and laterally rotating the hip

Superior gemellus

smaller than inferior gemellus  \n Origin: \n - external surface of the ischial spine  \n Insertion: \n - medial side of greater trochanter via conjoined tendon with obturator internus

Obturator externus

Location: \n - located deep to quadratus femoris \n - anterior to the obturator internus muscle  \n Action: \n Laterally rotates the hip

Gluteus minimus

Origin: \n - external (gluteal) surface of the ilium between the inferior and anterior gluteal lines  \n - gluteal (external) surface of the ilium \n Insertion: \n - anterolateral aspect of greater trochanter —> therefore attaches further forwards than gluteus medius muscle \n Action: \n - hip abduction and internal rotation \n - walking: stance leg muscles contract to keep pelvis level

What is the Trendelenburg sign?

drop of pelvis when lifting leg opposite due to weak gluteus medius and minimus

Inferior gemellus

Origin: \n - upper aspect of ischial tuberosity  \n Insertion: \n - anteromedial surface of greater trochanter via common tendon with superior gemellus and obturator internus

Superior gluteal nerves

Direction: \n 1. Exists greater sciatic foramen above the piriformis  \n 2. Travels laterally between gluteus minimus and medius muscles to reach the tensor fascia lata muscle  \n Supplies: muscular branches \n 1. Gluteus medius \n 2. Gluteus minimus \n 3. Tensor fascia lata

Inferior gluteal nerve

Location:  \n 1. exits greater sciatic foramen below the piriformis muscle  \n 2. Then travels on underside of gluteus maximus to then send off many muscular branches  \n Supplies: \n - gluteus maximus muscle

Pudendal nerve

Location: \n - most medial nerve \n - exits greater sciatic foramen below the piriformis  \n - reenters pelvis through the lesser sciatic foramen  \n Supplies: \n - sensation to external genitalia and perineum \n - some motor supply to muscles of the pelvic floor  \n - no structures in the gluteal region

Posterior cutaneous nerve of thigh

Location: \n - exits greater sciatic foramen below piriformis  \n Cutaneously Supplies: \n 1. Posterior muscles of thigh  \n 2. Leg \n 3. Foot

Nerve to quadratus femoris

Origin: \n Sacral plexus \n Formed by spinal nerves L4-S1 \n Location: \n Exits the greater sciatic foramen below the piriformis muscle \n - under the sciatic nerve and deep to the gemelli and obturator internus  \n Supplies: \n - inferior gemellus \n - quadratus femoris  \n Supplied by only spinal nerves L5-S1

Nerve to obturator internus

Origin: \n Sacral plexus \n Formed by spinal nerves of L5 - S2 \n Location: \n Exits greater sciatic foramen below piriformis to enter gluteal region \n Supplies: \n - superior gemellus \n - obturator internus  \n These muscles are only supply by spinal nerves L5-S1

Piriformis

Location:  \n 1. Passes through greater sciatic foramen into gluteal region  \n Origin: \n - anterior aspect of sacrum between 1st and 4th anterior sacral foramina  \n - also some attachments from greater sciatic notch and sacrotuberous ligament  \n Insertion: \n - medial side of superior surface of the greater trochanter

Other action of piriformis

Abduct hip from flexed position but this is weaker

Sciatic nerve tibial division

Supplies: \n L5-S2 \n 1. long head of biceps femoris  \n 2. Semitendinosus  \n 3. Semimembranosus

What are the 6 deep gluteal muscles

Action: \n Lateral rotator muscles  \n - resist excessive hip flexion and internal rotation at heel strike in walking and running  \n - compress the head of the femur into the acetabulum (especially when the hip is near extension and is some lateral rotation) \n - hence more stabilizing like role  \n Location: \n Lie posterior to the hip joint \n - run from pelvis —> attaches to the posterior femur around the greater trochanter or intertrochanter crest area  \n Piriformis \n Superior gemellus \n Obturator internus \n Inferior gemellus  \n Quadratus femoris \n Obturator externus

Sciatic nerve common peroneal nerve division

Supplies: \n L5-S2 \n - short head biceps femoris

Obturator internus

Origin: \n Inside of pelvis, from the interior suface of the obturator membrane and surrouding bone  \n Direction: \n - fibres travel posterior, laterally, and upwards, towards the lesser sciatic foramen —> form several tendonous bands on the surface of the muscles that contacts the bone pelvis  \n - then travels out of pelvis —> lesser sciatic foramen —> gluteal region  \n - then 90 degree turn around edge of posterior ischium between ischial spine and ischial tuberosity —> \n Insertion: \n Anteromedial surface of the greater trochanter \n - between trochanteric fossa and piriformis insertion

Superior gluteal artery

Direction: \n 1. Exits greater sciatic foramen above the level of piriformis  \n 2. Travels with gluteal superior nerve  \n - supplies medius and minimus and tensor fascia latae

Inferior gluteal artery

Direction: \n 1. Exits pelvis thorugh the greater sciatic foramen below piriformis \n 2. Travels with inferior gluteal nerve  \n \n supplies gluteus maximus

Obturator externus other action

Lateral rotation from a flexed position \n 2. Adducation form flexed position

trochanteric fossa

depression on medial and posterior surface of greater trochanter

What are the triceps Coxae muscles

Superior and inferior gemellus and obturator internus  \n All three insert: \n Via a common tendon on the greater trochanter  \n Action: only laterally rotate hip

Nerve supply of superior gemellus, Nerve supply of obturator internus

nerve to obturator internus \n Nerve roots: \n L5 \n S1

Quadratus femoris

Origin: \n -lateral margins of ischium just above ischial tuberosity  \n \n Insertion: \n - quadrate tubercle on the intertrochanteric crest of the femur

POSTERIOR THIGH MUSCLES

Contains 3 muscles: hamstring muscles  \n 1. Biceps femoris (long and short head) \n 2. Semimembranous \n 3. Semitendinous \n Origin: \n - all have commmon origin = ishcial tuberosity except for the short head of biceps femoris (posterior femur)  \n Action: they extend through two joints: hip and knee \n - all except short head of femoris —> knee flexion and hip extension \n - biceps femoris short head —> only flexes the knee joint  \n Extend hip/pelvis to return trunk upright when in a flexed position with tibia fixed to ground  \n Nerve supply: \n Sciatic nerve (this is the only nerve that runs through the posterior compartment of the thigh)

Obturator externus

obturator nerve \n - more similar to medial thigh muscles  \n Origin: \n - external surface of obturator membrane \n - adjacent bony margins of obturator foramen  \n Direction: \n - fibres travel along inferior margin of acetabulum  \n Insertion: \n - trochanteric fossa on the femur

Hamstring tendons

semitendiniosos

semimembransous

biceps femoris

Nerve supply obturator externus

obturator nerve - posterior branch \n Nerve roots: \n L3 \n L4

Nerve supply of inferior gemellus

nerve to quadratus femoris \n Nerve roots: \n L5 \n S1

Other action of quadratus femoris

Also lateral rotation in flexed position (not just anatomical)

Bicep femoris - long head

Location: \n - most lateral hamstring muscle  \n Origin: \n - inferior medial aspect of upper ischial tuberosity  \n Insertion: \n - common tendon with short head —> head of fibula on lateral side of knee \n Nerve supply: \n 1. Sciatic - tibial division \n Nerve roots: \n L5 \n S1 \n S2

Bicep femoris - short head

Location: \n Underneath the long head \n Origin: \n Shaft of femur along the lateral lip of the linea aspera  \n Insertion: \n - common tendon with long head onto head of fibular on lateral side of knee  \n Nerve supply: \n Sciatic nerve - common peroneal division \n Nerve roots: \n L5 \n S1 \n S2

Semitendinosus

Location: \n - covers much of the semimebranosus muscle for a lot of its course \n Origin: \n - shares common tendon with long head bicep femoris —> inferior medial aspect of ischial tuberosity  \n Insertion:  \n - wraps around medial aspect of knee and imserts on anteromedial surface of proximal tibia \n Nerve supply: \n Sciatic nerve - tibial division \n Nerve roots: \n L5 \n S1 \n S2

Semimembranosus

location:

Most medial and located under semitendinosus for much of its course \n Origin: \n - superolateral impression on the ischial tuberosity  \n Insertion:  \n Travels downwards and around the medial side of the knee —> inserts on posterior surface of medial tibial condyle  \n Nerve supply: \n Sciatic nerve - tibial division  \n Nerve roots: \n L5 \n S1  \n S2

intertrochanteric crest

region formed posteriorly between the greater and lesser trochanters

Nerve supply of quadratus femoris

nerve to quadratus femoris \n \n Nerve roots: \n L5 \n S1

Posterior compartment of the thigh

Begins at level of gluteal folds —> extends down to popliteal region behind the knee

biceps femoris

Insertion: head of fibula on lateral side of knee

Nerve to piriformis

Origin: \n - Sacral plexus  \n - Formed by Anterior rami of S1 and S2 \n Direction: \n - does not exit pelvis —> passes directly to piriformis

Obturator nerve

Origin: \n - lumbar plexus  \n - spinal nerves of L2-L4 \n Direction: \n - exits the pelvis through the obturator foramen to enter the medial thigh  \n Supplies: \n - obturator externus muscle  \n - supplied by only L3-L4 spinal nerves