Gluteal Region, Hip Joint, and Posterior Thigh | Gross HSB A o Piriformis

1st Year – 1st Semester – Midterms – 2nd Week (Valera, M.D.)

▪ Origin – pelvic part of sacrum & sacrotuberous ligament
Important muscles & structures (a checklist) ▪ Insertion – greater trochanter
✓ Gluteus maximus ▪ Nerve supply – sacral plexus (ventral rami of L5, S1, and S2)
✓ Gluteus medius ▪ Action – laterally-rotates the thigh
✓ Gluteus minimus ▪ Note: Important landmark of the gluteal region as its inferior border
✓ Tensor fasciae latae is where the sciatic nerves & other nerves come out
✓ Piriformis o Gemellus superior
✓ Gemellus superior ▪ Origin – ischial spine
✓ Gemellus inferior ▪ Insertion – obturator internus tendon
✓ Obturator internus ▪ Nerve supply – nerve to obturator internus
✓ Quadratus femoris ▪ Action – laterally-rotates the thigh
✓ Iliotibial tract o Obturator internus
✓ Superior & inferior gluteal ▪ Origin – ischiopubic rami
nerve, artery, and vein ▪ Insertion – greater trochanter
✓ Posterior femoral cutaneous nerve ▪ Nerve supply – nerve to obturator internus
✓ Internal pudendal nerve ▪ Action – laterally-rotates the thigh
✓ Sciatic nerve o Gemellus inferior
✓ Sacrotuberous ligament ▪ Origin – ischial tuberosity
✓ Sacrospinous ligament ▪ Insertion – obturator internus tendon
✓ Hamstring muscles (biceps femoris, ▪ Nerve supply – nerve to quadratus femoris
semitendinosus, and semimembranosus) ▪ Action – laterally-rotates the thigh
✓ Common peroneal nerve o Quadratus femoris
✓ Deep femoral artery ▪ Origin – ischial tuberosity
✓ Head of femur & acetabulum of hip bone ▪ Insertion – intertrochanteric crest
✓ Iliofemoral ligament ▪ Nerve supply – nerve to quadratus femoris
✓ Ischiofemoral ligament ▪ Action – laterally-rotates the thigh
✓ Pubofemoral ligament o Tensor fasciae latae
✓ Ligamentum teres femoris ▪ Origin – iliac crest
✓ Transverse acetabular ligament ▪ Insertion – iliotibial tract
Gluteal region ▪ Nerve supply – superior gluteal nerve
▪ Composition – buttocks & hip ▪ Action – abducts, medially-rotates, and flexes the thigh at the hip
▪ Borders of the gluteal region • Also, helps to keep the knee extended
o Superior – iliac crest o Note: Superior & inferior gluteal artery supplies blood for all the muscles
o Inferior – gluteal/skin fold (underlying buttocks) of this region
o Medial – intergluteal/nasal cleft Posterior thigh
o Lateral – greater trochanter/anterior superior iliac spine (ASIS) ▪ Muscles of the posterior thigh (hamstring muscles)
o Note: Gluteal muscles constitute the bulk of the region o Biceps femoris
▪ Surface anatomy of the gluteal region ▪ Origins
o Iliac crest • Long head – ischial tuberosity
▪ ASIS – anterior superior iliac spine • Short head – femoral shaft
▪ PSIS – posterior superior iliac spine ▪ Insertion – head of fibula
▪ Iliac tubercle – 2 inches behind the ASIS ▪ Action – flexes the knee
▪ Sacroiliac joint • Also, long head extends the thigh
o Ischial tuberosity o Semitendinosus muscle
o Greater trochanter ▪ Origin – ischial tuberosity
o Median sacral crest ▪ Insertion – medial surface of tibia
o Coccyx – 1 inch above the anus ▪ Action – flexes the knee & extends the thigh
o Folds of the buttocks ▪ Note: Slim & narrow muscle whose composition is ½ tendon
▪ Superior fascia of the gluteal region o Semimembranosus muscle
o Characteristic – considerable adipose tissue (only present in the gluteal) ▪ Origin – ischial tuberosity
o Contents – special blood vessels & cutaneous nerve endings ▪ Insertion – medial condyle of tibia
▪ Deep fascia of the gluteal region ▪ Action – flexes the knee & extends the thigh
o Iliotibial tract (thickened part of the fascia lata) ▪ Note: Broad muscle which occupies the floor of the posterior thigh
o Fascia lata – on the thigh o Note: All hamstring muscles originate from the ischial tuberosity &
o Intermuscular septa – divides the thigh into three muscle compartments extends the thigh except the short head of biceps femoris
(extensor/anterior, medial/adductor, and flexor/posterior) o Common nerve supply – sciatic nerve (divides into two nerves)
▪ Composed of three septa – lateral, medial, and posterior septa ▪ Common peroneal nerve – short head of biceps femoris
▪ Muscles of the gluteal region ▪ Tibial nerve – all other hamstring muscles
o Gluteus maximus o Common blood supply – perforating branches of profunda femoris artery
▪ Origin – ileum Blood supply of the thigh
▪ Insertion – gluteal tuberosity ▪ Femoral artery
▪ Nerve supply – inferior gluteal nerve o Origin – external iliac artery
▪ Action – chief extensor & most lower ▪ Demarcation – beyond the transverse inguinal ligament
lateral rotator of the thigh o Path – femoral triangle to the adductor canal passing inside the
o Gluteus medius adductor hiatus to occupy the popliteal fossa
▪ Origin – ileum o Branches of the femoral artery
▪ Insertion – greater trochanter ▪ Superficial epigastric artery
▪ Nerve supply – superior gluteal nerve ▪ Superficial circumflex iliac artery
▪ Action – abducts & medially-rotates the thigh ▪ Superficial external pudendal artery
▪ Note: Only G. medius & G. minimus are in charge of medial rotation ▪ Deep external pudendal artery
and damage to greater trochanter → lack of medial rotation ▪ Deep femoral (profunda femoris) artery
o Gluteus minimus ▪ Descending genicular artery
▪ Origin – ileum o Branches of the profunda femoris – most important branch for the
▪ Insertion – greater trochanter posterior thigh muscles
▪ Nerve supply – superior gluteal nerve ▪ Four perforating branches – supply the muscles of posterior thigh
▪ Action – adbuctors & medially-rotates the thigh
 ▪ Medial & lateral circumflex femoral artery o Anterior division fusions:
• Cruciate anastomosis ▪ Nerve to quadratus femoris & inferior gemellus
o Components of the cruciate anastomosis • Origin – L4 to S1
▪ Medial circumflex femoral artery ▪ Nerve to obturator internus & superior gemellus
▪ Lateral circumflex femoral artery • Origin – L5 to S2
▪ First perforating artery ▪ Pudendal nerve
▪ Inferior gluteal artery • Origin – S2 to S4
o Importance – equivalent to the circle of Willis in the brain ▪ Nerve to levator ani & coccygeus
o Function – ensures that there is constant blood supply in • Origin – S3 & S4
the hip joint area ▪ Perineal nerve
o Clinical correlation – hip fracture near the neck of the femur • Origin – S4
can lead to avascular necrosis if the cruciate anastomosis o Posterior division fusions:
is compromised → total hip replacement procedure ▪ Superior gluteal nerve
▪ Although, a small branch of the obturator artery is still • Origin – L4 to S1
supplying the head of femur – this is not sufficient ▪ Inferior gluteal nerve
Venous drainage of the thigh • Origin – L5 to S2
▪ Superficial set of veins ▪ Piriformis
o Long (greater) saphenous vein • Origin – S1 & S2
▪ Path – from front of the medial malleolus & behind the medial ▪ Perforating cutaneous nerve
condyle of the tibia → the medial aspect of the femur → reaches
• Origin – S2 & S3
the groin & pierces the deep fascia
Sciatic foramen
▪ Importance – common site for venous cutdown
▪ Sacrospinous ligament – divides the sciatic foramen to greater & lesser
o Short (lesser) saphenous vein
portions
▪ Path – from the lateral malleolus → popliteal fossa → merges with
▪ Divisions of the sciatic foramen:
the femoral vein
o Greater sciatic foramen
▪ Deep set of veins
▪ Piriformis – further divides the greater sciatic foramen
o Venae commitantes – veins which accompany the arteries which
o Lesser sciatic foramen
supplies the muscles of the thigh
o Note: Remember the structures transmitted per foramen
o Note: They are named according to their corresponding arteries
Lymphatic drainage of the thigh
▪ Superficial set of lymph vessels
o Location – accompanies the greater & lesser saphenous veins
o Node drainage – superficial inguinal nodes
▪ Receive lymph from the following sites:
• Greater saphenous vein
• Lower abdomen
• Perineum
• Scrotum, penis, and vulva
• Gluteal region Hip/coxal joint
▪ Note: Further drain into the external iliac nodes ▪ Type of joint – multiaxial ball & socket synovial joint
o Superficial inguinal lymph nodes ▪ Location – between the acetabulum of the hip bone & head of femur
▪ Shape – T-shaped ▪ Action – abduction, adduction, flexion, extension, circumduction, and
▪ Horizontal group rotation of the thigh
• Number – more nodes compared to vertical lymph nodes ▪ Stabilization – acetabular labrum, fibrous capsule, and capsular ligaments
• Structures drained: ▪ Blood supply – branches of the lateral & medial femoral circumflex, superior
o Abdominal wall & inferior gluteal, and obturator arteries
o Gluteal region ▪ Nerve supply – branches of the femoral, obturator, sciatic, superior gluteal,
o Scrotum, penis, vulva and by the nerve to quadratus femoris
▪ Vertical group ▪ Ligaments which adds strength to the articular capsule:
• Number – less nodes compared to horizontal lymph nodes ▪ Iliofemoral ligament (Y-ligament of Bigelow)
• Structures drained: • Shape – inverted Y-shape
o Greater saphenous vein (from lower limb) • Attachment – anterior acetabular labrum/fibrous capsule
▪ Deep set of lymph vessels • Function – anterior reinforcement of the acetabular labrum
o Location – accompanies the deep blood vessels (near popliteal) ▪ Pubofemoral ligament
o Node drainage – popliteal nodes • Attachment – pubis to femur
▪ Note: Further drain into the deep inguinal nodes & subsequently to • Function – inferior reinforcement of the capsule
the external iliac nodes o Also, limits extension & abduction of the thigh
Sacral plexus (nerve supply to the lower limb) ▪ Ischiofemoral ligament
▪ Importance – innervates the gluteal region & posterior thigh • Function – posterior reinforcement of the capsule
▪ Origin – ventral rami of the L4, L5, S1, S2, S3, S4 (L4 to S4) o Also, limits extension & medial rotation of the thigh
▪ Note: Similar to the brachial plexus for the upper limbs Whenever a doctor cannot do good, he must be kept from doing harm.
▪ Formation of the sacral plexus: Hippocrates

o All ventral rami of L4 to S3 → anterior & posterior branches

AngeloBautista

▪ Note: Only S4 does not divide into anterior & posterior branches
o All anterior branches → preaxial nerves
o All posterior branches → postaxial nerves
▪ Derivatives of the sacral plexus:
o Sciatic nerve
▪ Origin – fusion of the anterior & posterior division of L4 to S3
▪ Importance – supplies posterior compartment of the thigh
▪ Common peroneal nerve – from the posterior fusion
• Note: Vulnerable nerve as its path leads it around the
neck of the fibula → foot drop (foot is plantarflexed & inverted)
▪ Tibial nerve – from the anterior fusion
o Posterior femoral cutaneous nerve
▪ Origin – fusion of anterior & posterior division of S1 to S3