Lectures of Human Anatomy

Transcription

1 Lectures of Human Anatomy Lower Limb Gluteal Region and Hip Joint By DR. ABDEL-MONEM AWAD HEGAZY M.B. with honor 1983, Dipl."Gynecology and Obstetrics "1989, Master "Anatomy and Embryology" 1994, M.D. "Anatomy and Embryology" 1999 Associate Professor of Anatomy and Embryology Faculty of Medicine, Zagazig University (Egypt) & College of Medicine, Majmaah University (Saudi Arabia)

2 Gluteal Region Muscles 1. Gluteal muscles include: - Tensor fasciae latae, - Gluteus maximus, - Gluteus medius and - Gluteus minimus. Gluteal muscles are generally originated from the outer surface of iliac bone and inserted into iliotibial tract and upper lateral part of femur. Nerve supply: Superior gluteal nerve supplies: - tensor fasciae latae, - gluteus medius, - gluteus minimus. Inferior gluteal nerve supplies: "gluteus maximus". 2. Lateral rotators (6 small muscles) of the thigh: - Piriformis, - Two obturators (internus and externus), - Two gemelli (superior and inferior) - Quadratus femoris. Tensor fasciae latae Origin: Iliac crest (anterior part of outer lip of iliac crest, behind the anterior superior iliac spine). Insertion: into the iliotibial tract. Nerve supply: Superior gluteal nerve. Action: 1. Through its attachment with iliotibial tract, it helps in fixation of femur on tibia during standing. 2. It helps in abduction and medial rotation of thigh. 3. It helps in extension and lateral rotation of leg. Gluteus maximus It is the largest and most superficial muscle. Origin: - Outer (gluteal) surface of iliac bone, behind the posterior gluteal line. - Back of sacrum and coccyx. - Back of sacrotuberous ligament.

3 Insertion: - Greater part (three-quarters) of the muscle is inserted into iliotibial tract. - Small part (lower deep quarter) of the muscle is inserted into gluteal tuberosity of femur. Nerve supply: Inferior gluteal nerve. Action: 1. Through its attachment with iliotibial tract, it helps in fixation of femur on tibia during standing. 2. Extension of the thigh at hip joint. 3. Lateral rotation of the thigh, when the thigh is extended. N.B.: It is commonly used for intramuscular injection, as it is a thick and fleshy muscle. The injection is usually done in the upper lateral quadrant of the muscle, to avoid the sciatic nerve and its branches, that pass through the other quadrants. N.B.: Tensor fasciae latae and gluteus maximus muscles form what is called deltoid of hip joint. The anterior and lateral part represented by the first muscle forms the anterior part of deltoid acting in flexion, abduction and medial rotation of hip joint. The second muscle "gluteus maximus" forms the posterior part functions in extension and lateral rotation of hip joint. Gluteus medius Origin: Outer (gluteal) surface of iliac bone, (middle portion between the posterior and middle gluteal lines). Insertion: Lateral surface of greater trochanter of femur. Nerve supply: Superior gluteal nerve. Gluteus minimus Origin: Outer (gluteal) surface of iliac bone, (anterior portion between the middle and inferior gluteal lines). Insertion: Anterior surface of greater trochanter of femur. Nerve supply: Superior gluteal nerve Action of gluteus medius and minimus: 1. Abduction of the thigh at the hip joint. 2. Medial rotation of the thigh. 3. Prevention of tilt of the pelvis on the opposite unsupported side. Their contraction prevents sagging of the pelvis, when the foot is raised from the ground. Therefore, their paralysis leads to waddling (totter) gait. In this case, the patient involuntary flexes his trunk to one side when he

4 raises his foot on the opposite side, to prevent dropping of the pelvis. Iliotibial tract - It is the thickened lateral part of deep fascia of the thigh "fascia lata". - Extension: It extends from the iliac tubercle of hip bone to the lateral condyle of tibia. - Muscle attachments: It receives the insertion of 2 muscles; tensor fasciae latae and greater part (superficial three-quarters) of gluteus maximus. - Function: It helps to steady the femur on tibia during standing through muscles attached to it, when the knee extensors are relaxed. Attachments of muscles to back of hip bone and upper femur

5 Photograph showing front of thigh and tensor fasciae latae Piriformis Origin: It arises in the pelvis, from the middle three pieces of sacrum. Insertion: It comes out of the pelvis through the greater sciatic foramen to be inserted into the top (upper border) of the greater trochanter of femur. Nerve supply: First and second sacral nerves (S 1,2 ). Action of all six lateral rotators: - Lateral rotation of thigh at hip joint. - Control of the hip joint movements (stabilizing hip joint). Obturator internus Origin: from the inner surface of obturator membrane and the adjoining part of pelvic surface of hip bone. Insertion: through a tendon, coming out the pelvis through the lesser sciatic foramen to be inserted into the inner (medial) surface of greater trochanter of femur (above trochanteric fossa). Nerve supply: Nerve to obturator internus (a branch from sacral plexus L 5,S 1 ). Action: Like piriformis.

6 Obturator externus Origin: from the outer (external) surface of obturator membrane and the adjoining part of outer surface of hip bone. Insertion: The tendon passes below and then behind the neck of femur to be inserted into trochanteric fossa. Nerve supply: Obturator nerve (posterior division). Action: Like piriformis. Quadratus femoris Origin: Lateral border of ischial tuberosity. Insertion: The muscle passes laterally to be inserted into the quadrate tubercle of femur and bone below it. Nerve supply: Nerve to quadratus femoris (a branch from sacral plexus L 5,S 1 ). Action: Like piriformis. Gemelli (superior and inferior gemellus) Origin: from the margin of lesser sciatic notch. Insertion: into the tendon of obturator internus. Nerve supply: Nerve to obturator internus (a branch from sacral plexus L 5,S 1 ) supplies superior gemellus. Nerve to quadrates femoris (a branch from sacral plexus L 5,S 1 ) supplies inferior gemellus. Action: Like piriformis.

7 Photograph showing gluteal region Photograph showing obturator membrane and sacrospinous and sacrotuberous ligaments Sciatic Foramina 1. Greater sciatic foramen Boundaries: 1. Greater sciatic notch. 2. Sacrotuberous ligament. 3. Sacrospinous ligament. Structures passing through it: (ONE muscle plus vessels and nerves) I. Piriformis.

8 II. Structures passing above piriformis: 1- Superior gluteal nerve. 2- Superior gluteal vessels. III. Structures passing below piriformis: A. Structures reaching gluteal region: 1- Inferior gluteal nerve. 2- Inferior gluteal vessels. 3- Nerve to quadratus femoris. B. Structures extending downwards to the back of thigh: 1- Sciatic nerve. 2- Posterior cutaneous nerve of the thigh. C. Structures extending forwards to perineum through lesser sciatic foramen: 1- Pudendal nerve. 2- Internal pudendal vessels. 3- Nerve to obturator internus. 2. Lesser sciatic foramen Boundaries: 1. Lesser sciatic notch. 2. Sacrotuberous ligament. 3. Sacrospinous ligament. Structures passing through it: (ONE muscle plus vessels and nerves) 1. Obturator internus. 2. Nerve to obturator internus. 3. Internal pudendal vessels. 4. Pudendal nerve. Hip Joint Type of the joint: Synovial "ball-and-socket" joint. Articular parts: 1. Head of femur. 2. Acetabulum of hip bone. N.B.: The articular part of acetabulum is a horse-shoe shaped. The central and inferior parts of acetabulum do share in articulation. The central part is fat-filled depression, called the acetabular fossa. The inferior deficient

9 part of acetabulum (called acetabular notch) is closed by a transverse ligament, from which the ligamantum teres arises to reach the fovea of head of femur. The depth of acetabulum is augmented by attachment of a fibro-cartilaginous rim called acetabular labrum to its edge. This labrum bridges over the acetabular notch forming the transverse ligament. Attachment of joint capsule: Proximally: It is attached to the margins of acetabulum and the transverse ligament. Distally: It is attached as follows: - Laterally to the medial aspect of the greater trochanter. - Anteriorly to the intertrochanteric line. - Medially to base of neck of femur. - Posteriorly to the neck of femur, about half an inch proximal to the intertrochanteric crest. Capsular Ligaments: There are 3 ligaments that surround and strengthen the capsule; each of them arises from one of the three bones forming the hip bone; 1. Ilio-femoral ligament: It is a Y-shaped ligament, passing on the anterior aspect of the capsule. It arises from the anterior inferior iliac spine, then bifurcates to reach both ends of intertrochanteric line of femur. It is the strongest ligament, preventing hyperextension of hip joint. 2. Pubo-femoral ligament: It arises from the iliopectineal junction, iliopectineal eminence and superior pubic ramus, passing on the medial aspect of the capsule to blend with the deep surface of iliofemoral ligament to the trachanteric line. 3. Ischio-femoral ligament: It arises from the ischium, passing on the posterior aspect of the capsule to reach the base of the greater trochanter of femur. Stability of hip joint: This depends mainly on: 1. Shape of the articulating bones:. Head of femur is completely fitted into deep socket, formed by acetabulum. 2. Three strong extra-capsular ligaments: - Ilio-femoral ligament: It is the strongest ligament in the body. It resists hyperextension of the joint. - Pubo-femoral ligament.

10 - Ischio-femoral ligament. Nerve supply of hip joint: According to Hilton's law, the nerves supplying the muscles moving a joint also supply the joint. Hip joint is supplied by arteries crossing the joint including: femoral, sciatic and obturator nerves. These nerves are the same that supply the knee joint. Arterial supply of hip joint: Obturator, medial circumflex femoral, superior gluteal and inferior gluteal arteries. Movements of Hip Joint I. Abduction: produced by 1. Gluteus medius 2. Gluteus minimus 3. Tensor fasciae latae II. Adduction: produced by adductor group of muscles; 1. Adductor longus 2. Adductor brevis 3. Adductor magnus 4. Gracilis 5. Pectineus. III. Flexion: produced by 1. Ilio- psoas major, assisted by 2. pectineus, 3. sartorius, 4. rectus femoris. IV. Extension: produced by 1. Gluteus maximus 2. The hamstrings; semitendinosus, semimembranosus, biceps femoris and hamstring portion of adductor magnus. V. Circumduction: Combination of the previous movements, done respectively in series. VI. Medial rotation: produced by 1. Tensor fasciae latae. 2. Gluteus medius 3. Gluteus minimus

11 VII. Lateral rotation: produced by small '6' lateral rotators and gluteus maximus; 1. Piriformis, 2. Two obturators; obturator externus and obturator internus. 3. Two gemelli; superior gemellus and gemellus inferior. 4. Quadratus femoris. 5. Gluteus maximus. Bursa Related To Hip Joint Psoas bursa - It is a bursa, underlying the psoas tendon in-front of the hip joint. It is found in 10% of people. - It represents an outpouching of synovial membrane of the joint through a defect in its anterior capsular wall.