Anterior and Medial compartments of the thigh. Dr. Heba Kalbouneh Associate Professor of Anatomy and Histology

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1 Anterior and Medial compartments of the thigh Dr. Heba Kalbouneh Associate Professor of Anatomy and Histology

2 Terms Related to Movements Movement Flexion Extension Abduction Adduction Medial (internal) rotation Lateral (external) rotation Elevation Depression Protraction Retraction Opposition Definition A movement that decreases the angle between two body parts A movement that increases the angle between two body parts A movement away from the midline A movement towards the midline A rotational movement towards the midline A rotational movement away from the midline A movement in a superior direction A movement in an inferior direction Anterior movement of the jaw Posterior movement of the jaw The movement that involves grasping of the thumb and fingers

3 Movement Supination Pronation Dorsiflexion Plantarflexion Definition A rotational movement where the forearm and palm are turned outwards A rotational movement where the forearm and palm are turned inwards Movement at the ankle, so that the foot points more superiorly Movement at the ankle, so that the foot points inferiorly Inversion Eversion Circumduction The movement of the sole towards the median plane so that the sole faces in a medial direction The movement of the sole away from the median plane so that the sole faces in a lateral direction A conical movement of a body part. Circumduction is a combination of flexion, extension, adduction and abduction.

4 Plantarflexion of foot The foot points inferiorly

5 Dorsiflexion of foot The foot points more superiorly

6 Inversion of foot The movement of the sole towards the median plane so that the sole faces in a medial direction

7 Eversion of foot The movement of the sole away from the median plane so that the sole faces in a lateral direction

8 Superficial veins are those closer to the surface of the body, and have no corresponding arteries. They return blood from skin and subcutaneous structures by anastomosing (inter-connecting) with deep veins Deep veins are deeper in the body and accompany the principle arteries and usually have the same name Superficial veins can be seen under the skin

9 Superficial veins of lower limb Large veins embedded in the subcutaneous (superficial) fascia are: Great (long) saphenous vein Drains the medial end of the dorsal venous arch. Small (short) saphenous vein Drains the lateral end of the dorsal venous arch. At the knee. The great saphenous vein s surface marking is classically one hand's breadth posterior to the medial border of the patella or just posterior to the medial condyle of the femur.

10 Superficial veins of lower limb Great (long) saphenous vein Passes up the medial side of the leg, knee, and thigh Ascends in company with the Saphenous nerve Passes through the Saphenous opening Joins the femoral vein (in front of medial malleolus) Small (short) saphenous vein Passes up the back of the leg to penetrate the deep fascia and join the popliteal vein in the popliteal fossa Ascends in company with the Sural nerve (behind lateral malleolus)

11 The normal flow of blood in the lower limbs is from skin and subcutaneous tissues to the superficial veins, which drain by perforating veins to the deep veins, which in turn drain into the iliac veins and inferior vena cava Perforating vein Deep vein Superficial vein

12 Fascia lata: Is a strong fibrous sheet that surrounds the whole of the thigh like a tight trouser. Thick on its lateral side to form the iliotibial tract Saphenous opening is an oval opening in the upper part of the fascia lata of the thigh. Its center lies 1.5 inch below and lateral to the pubic tubercle and is about 3 cm long and 1.5 cm wide The saphenous opening is filled with loose connective tissue called the cribriform fascia

13 Iliotibial tract Is a strong wide band (thickening of the deep fascia (fascia lata)) on the lateral side of the thigh) attached above to the iliac tubercle and below to the lateral condyle of tibia. Gluteus maximus Tensor fascia latae Receives the insertion of tensor fascia latae and gluteus maximus muscles

14 Deep fascia of the thigh (fascia lata) Fascia lata is connected to the linea aspera by three intermuscular septa; 1-Medial intermuscular septum 2-Lateral intermuscular septum 3-Posterior intermuscular septum

15 Anterior Fascial Compartments of the Thigh Contents of the Anterior Fascial Compartment of the Thigh 1-Muscles: Sartorius, iliacus, psoas, and quadriceps femoris, pectineus 2-Blood supply: Femoral artery 3-Nerve supply: Femoral nerve Note: Not all the contents of the anterior compartment have the same function. For example illopsoas is the main flexor of the thigh at the hip joint while quadriceps femoris is the main extensor of the leg at the knee joint

16 Iliacus Origin: Iliac fossa Insertion: with psoas into lesser trochanter Nerve supply: Femoral nerve Action: Flexes thigh on trunk; if thigh is fixed, it flexes the trunk on the thigh as in sitting up from lying down Lesser trochanter

17 Psoas Origin: Transverse processes, bodies, and intervertebral discs of the 12th thoracic and lumbar vertebrae Insertion: With iliacus into lesser trochanter Nerve supply: Lumbar plexus Action: Flexes thigh on trunk; if thigh is fixed, it flexes the trunk on the thigh as in sitting up from lying down

18 Iliopsoas

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20 Quadriceps femoris

21 Rectus femoris Origin: Straight head: anterior inferior iliac spine (AIIS) Reflected head: ilium above acetabulum Insertion: Quadriceps tendon into patella, then via ligamentum patellae into tibial tuberosity Nerve supply: Femoral nerve Action: Extension of leg at knee joint; flexes thigh at hip joint

22 Vastus lateralis Vastus= Great or Wide Origin: Shaft of femur Insertion: Quadriceps tendon into patella, then via ligamentum patellae into tibial tuberosity Nerve supply: Femoral nerve Action: Extension of leg at knee joint

23 Vastus medialis Origin: Shaft of femur Insertion: Quadriceps tendon into patella, then via ligamentum patellae into tibial tuberosity Nerve supply: Femoral nerve Action: Extension of leg at knee joint; stabilizes patella

24 Vastus intermedius Origin: Shaft of femur Insertion: Quadriceps tendon into patella, then via ligamentum patellae into tibial tuberosity Nerve supply: Femoral nerve Action: Extension of leg at knee joint; articularis genu retracts synovial membrane

25 Sartorius Sartor = Tailor Origin: Anterior superior iliac spine (ASIS) Insertion: Upper medial surface of shaft of tibia (SGS) Nerve supply: Femoral nerve Action: Flexes, abducts, laterally rotates thigh at hip joint; flexes and medially rotates leg at knee joint Helps rotate the leg to the cross-legged position This name was chosen in reference to the cross-legged position in which tailors once sat

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27 The upper medial surface of shaft of tibia is called SGS area for the attachments of 3 muscles: The combined tendons of insertion are termed pes anserinus (goose foot) Sartorius Gracilis Semitendinosus

28 Pectineus Origin: Pectineal line of pubis Insertion: Pectineal line of femur Nerve supply: Femoral nerve Action: Flexes and adducts thigh at hip joint

29 Psoas Femoral nerve Is the largest branch of the lumbar plexus (L2, 3, and 4). It emerges from the lateral border of the psoas muscle Leaves the abdomen by passing through the gap behind the inguinal ligament Enters the thigh lateral to the femoral artery and the femoral sheath Innervates all muscles in the anterior compartment of the thigh Innervates skin over the anterior and medial aspects of the thigh, the medial aspect of the knee, leg and the foot (as far as the ball of the big toe) Femoral vein Femoral artery

30 Note that the femoral nerve does not enter the thigh within the femoral sheath Cutaneous branches 1- Medial cutaneous nerve of the thigh 2- Intermediate cutaneous nerve of the thigh 3- Saphenous nerve L2 L3 Muscular branches Iliacus Pectineus Sartorius Quadriceps femoris L4 Articular branches Hip joint Knee joint

31 Femoral nerve L2 L3 L4 Iliacus Inguinal ligament Pectineus Sartorius Quadriceps femoris

32 Femoral branch of genitofemoral nerve Ilio-inguinal nerve Lateral cutaneous nerve of the thigh Obturator nerve Femoral nerve (Intermediate and medial cutaneous nerves of thigh) Lateral Medial

33 Femoral nerve (Intermediate and medial cutaneous nerves of thigh) Femoral nerve Saphenous nerve THE SAPHENOUS NERVE Runs downward and medially. It emerges between the tendons of sartorius and gracilis It then runs down in company with the great saphenous vein. It passes in front of the medial malleolus Femoral nerve (Saphenous nerve) Supplies the medial side of the knee, leg and foot as far as the ball of the big toe

34 Saphenous nerve The saphenous nerve accompanies the femoral artery through the adductor canal, but does not pass through the adductor hiatus with the femoral artery. Rather, the saphenous nerve penetrates the deep fascia and appears between the sartorius and gracilis muscles on the medial side of the knee, and continues down the medial side of the leg to the foot, and supplies skin on the medial side of the knee, leg, and foot.

35 Medial Fascial Compartment of the Thigh Can you think of a bone that can be suitable to provide an origin for an adductor muscle of the hip joint? The Pubic bone Would you be able to think of a bone that can be a good insertion FOR the adductor muscles? The femur

36 Medial fascial compartment of the Thigh Contents of the Medial Fascial Compartment of the Thigh 1- Muscles: Pectineus, Adductor Longus, Adductor Brevis, Adductor Magnus, Gracilis Obturator externus 2-Nerve supply: Obturator nerve 3-Blood supply: Profunda femoris artery and obturator artery In the practical session Remember that the adductor muscles are arranged in three layers in similar way to that of the pages of the book The first layer (page) contains: pectineus and adductor longus The second layer contains: adductor brevis only The third layer contains: adductor magnus only

37 Action of the adductor muscles as a group 1- Adduct the thigh, although adduction of the thigh is not important in the mechanism of walking and standing 2-Because their origin is in front of the hip joint (in a plane that is in front of the hip joint) they can flex the thigh at the hip joint 3- They assist in medial rotation of the thigh

38 Gracilis Origin: Body, inferior ramus of pubis, ramus of ischium Insertion: Upper part of shaft of tibia on medial surface (SGS) Nerve supply: Obturator nerve Action: Adducts thigh at hip joint; flexes leg at knee joint

39 Adductor longus Origin: Body of pubis, inferior to pubic tubercle Insertion: Posterior surface of shaft of femur (linea aspera) Nerve supply: Obturator nerve Action: Adducts thigh at hip joint

40 Adductor brevis Origin: Body and inferior ramus of pubis Insertion: Posterior surface of shaft of femur (linea aspera) Nerve supply: Obturator nerve Action: Adducts thigh at hip joint

41 Adductor magnus Origin: Adductor part: Inferior ramus of pubis, ramus of ischium Hamstring part: ischial tuberosity Insertion: Adductor part: Posterior surface of shaft of femur Hamstring part: adductor tubercle of femur Nerve supply: Adductor part: obturator nerve Hamstring part: sciatic nerve Action: Adducts thigh at hip joint; hamstring portion extends thigh at hip joint

42 Obturator nerve L2 L3 Arises from the lumbar plexus (L2, 3, and 4) anterior divisions Emerges on the medial border of the psoas muscle Enters the thigh by passing through the obturator canal It divides into anterior and posterior divisions Supplies all muscles in the medial compartment except the hamstring part of adductor magnus and pectineus Supplies obturator externus Supplies the skin on the medial side of upper thigh L4 Femoral nerve (Intermediate and medial cutaneous nerves of thigh)

43 L2 L3 L4 Psoas Femoral nerve Obturator nerve

44 Descends on the anterior surface of adductor brevis The anterior division Muscular branches to 3 muscles : Gracilis, Adductor brevis, Adductor longus Articular branches to the hip joint Cutaneous branches to the skin on the medial side of the thigh. Descends on the posterior surface of adductor brevis The posterior division Muscular branches to 2 muscles : Obturator externus Adductor part of the adductor magnus Articular branches to the knee joint Referred pain Is the pain perceived at a location other than the site of the painful stimulus.

45 Hilton s law states that the nerves crossing a joint supply 1-The muscles acting on it 2-The skin over the joint 3-The joint itself For example, The hip receives fibres from the femoral, sciatic and obturator nerves. It is important to note that these nerves also supply the knee joint and, for this reason, it is not uncommon for a patient, particularly a child, to complain bitterly of pain in the knee and for the cause of the mischief, the diseased hip, to be overlooked

46 Articularis Genu Origin: Anterior surface of distal part of the shaft of the femur Insertion: Proximal part of the suprapatellar bursa (an extension of the synovial cavity of the knee joint) It is often part of the vastus intermedius. This muscle lies deep to the vastus intermedius Pulls the bursa away from the knee joint during extension Articularis: joint Genu: knee

47 Superficial fascia of the thigh Contents: 1- Cutaneous nerves 2- Superficial arteries 3- Superficial veins 4- Superficial inguinal lymph nodes

48 Genitofemoral nerve Skin of the thigh Ilioinguinal nerve Femoral nerve (Intermediate and medial cutaneous nerves of thigh)

49 3 2 1 Superficial arteries: 1- Superficial external pudendal artery: passes medial to external genitalia 2- Superficial epigastric artery: passes upward toward the umbilicus 3- Superficial circumflex iliac artery: passes laterally toward the iliac crest Femoral triangle All these are branches of femoral artery Lateral Medial

50 3 2 1 Superficial veins: Great saphenous vein and its tributaries The superficial veins that correspond to the superficial branches of the femoral artery drain into the great saphenous vein Femoral triangle Lateral Medial

51 Superficial inguinal lymph nodes Lies below the inguinal ligament Divided into two groups; horizontal and vertical. A-The horizontal group lies below and parallel to the inguinal ligament. B-The vertical group lies along the terminal part of Saphenous vein. Lymph nodes cannot be palpated or seen unless they are enlarged

52 Remember that if the patient presented to you with an enlarged superficial inguinal lymph nodes you should ask about and check the below mentioned areas Both groups (horizontal and vertical) receive superficial lymph vessels from: 1- All the lower limb 2- Gluteal region 3- Perineum (Lower half of anal canal, Distal urethra, Genitalia of both sexes (but not the testes)) 4- Anterior abdominal wall below umbilicus The efferent lymph vessels from the superficial inguinal nodes pass through the saphenous opening in the deep fascia and join the deep inguinal nodes

53 Great saphenous vein The horizontal group of lymph nodes

54 Great saphenous vein Saphenous opening transmits the great saphenous vein, some superficial branches of the femoral artery, and lymph vessels

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