Anatomy of the Lower Limb

Anatomy II- L 4

Gluteal Region

Prof. Dr. Malak Akram Taha

Department of Anatomy
 Objectives

• Describe the gluteal region

• List its muscles, vessels & nerves
• Specify the site of injection
• Demonstrate some important pathologies affecting
the structures in the region
 Gluteal Region: Buttocks and Hip Region

 The demarcation of the trunk and lower limb

 Anteriorly, is abrupt at the inguinal ligament,
 Posteriorly the gluteal region is a large transitional zone between
the trunk and limb.

 The gluteal region

 Physically part of the trunk,
 functionally part of the lower
limb
 The intergluteal cleft (natal cleft) is the groove that separates
the buttocks from each other.

 The gluteal fold demarcates the inferior boundary of the

buttock and the superior boundary of the thigh.

 The subcutaneous fat is well developed in this region

 Gluteal Region

 Boundaries
 the iliac crest above
 Gluteal fold below
 The region communicates with the
pelvic cavity and perineum through the
greater and lesser sciatic foramina
 Inferiorly, it is continuous with the posterior
thigh (hamstring comp).
 NERVES OF THE GLUTEAL AND POSTERIOR THIGH REGIONS
Nerve Origin Course Distribution

Superior Clunial posterior cross iliac crest

nerve rami of Supply skin of superior
L1-L3 buttock as far as
tubercle of iliac crest

Middle (Medial) posterior exit through Supply skin over sacrum

Clunial nerve rami of posterior and adjacent area of
S1-S3 sacral foramina and buttock
nerves enter gluteal
region

Inferior Clunial nerve posterior curve around inferior Supplies skin of inferior
cutaneous border of gluteus half of buttock as far as
nerve of maximus greater trochanter
thigh
 GLUTEAL LIGAMENTS

 The posterior sacroiliac ligament is continuous inferiorly with the

sacrotuberous ligament.
 The greater sciatic foramen is the passageway for structures
entering or leaving the pelvis (e.g., sciatic nerve), whereas the
lesser sciatic foramen is the passageway for structures entering
or leaving the perineum (e.g., pudendal nerve).
Muscles of Gluteal Region
The superficial layer The deep layer

 consists of the three large  consists of smaller muscles

overlapping glutei (piriformis, obturator
(maximus, medius, and internus, superior and
minimus) and the tensor inferior gemelli, and
fasciae latae quadratus femoris)
 all have proximal
attachments to the  all have distal attachments
posterolateral (external) on or adjacent to the
intertrochanteric crest of
surface and margins of the the femur.
ala of the ilium
 are mainly extensors,  are lateral rotators of the
abductors, and medial thigh, but they also
rotators of the thigh. stabilize the hip joint,
 Muscles of Gluteal Region

The superficial layer The deep layer

Muscle Origin Insertion N Supply Action

o Ilium posterior to o Most fibers o Extensor,

posterior gluteal end in abductor &
line; iliotibial lateral

Inferior gluteal nerve

o dorsal surface of tract, which rotator of
Gluteus Maximus

sacrum and coccyx; inserts into femur

(L5, S1, S2)

o sacrotuberous lateral
ligament condyle of
tibia;
o some fibers
insert on
gluteal
tuberosity
 The gluteus maximus contracts only briefly during the earliest
part of the stance phase .
 On climbing stairs , the gluteus maximus contract strongly.

 Paralysis of the gluteus

maximus does not seriously affect
walking on level ground.
Muscles Origin Insertion N Supply Action

External surface of Lateral surface o Abduct and medially

Gluteus
medius

ilium between of greater rotate thigh;

anterior and trochanter of o keep pelvis level
posterior gluteal lines femur when ipsilateral limb

Superior gluteal nerve

External surface of Anterior surface is weight-bearing
and advance
minimus

(L4, L5, S1)

Gluteus

ilium between of greater

anterior and inferior trochanter of opposite
gluteal lines femur (unsupported) side
during its swing
phase
Anterior superior Iliotibial tract,
fascia lata
Tensor of

iliac spine; anterior which attaches

part of iliac crest to lateral
condyle of tibia
 G Md

G Mn

G Mx
P

GS

OI

QF
-Glutei medius & minimus are
important in holding both hips at
the same level & preventing drop
of the lifted side during walking

-Their paralysis causes +ve

Trendelenburg sign (pelvis sags
down when the limb is not weight
bearing)
Muscles of Gluteal Region
The deep layer
Muscles Origin Insertion N Supply Action
Piriformis Anterior surface of Superior border Branches of
sacrum; sacrotuberous of greater anterior rami of
ligament trochanter of S1, S2
femur

Pelvic surface of Medial surface Nerve to

Obturator

 steady femoral head in acetabulum

internus

obturator membrane of greater obturator

and surrounding bones trochanter internus (L5,

 Laterally rotate extended thigh

(trochanteric S1,S2)
fossa) of femur
 Superior: ischial Medial surface Superior
Superior and inferior gemell

spine of greater gemellus: same

 abduct flexed thigh;

 Inferior: ischial trochanter nerve supply as
tuberosity (trochanteric obturator
fossa) of femur internus Inferior
gemellus: same
nerve supply as
quadratus
femoris
Muscles Origin Insertion N Supply Action

Lateral border of Quadrate Nerve to Laterally

Quadratus femoris

ischial tuberosity tubercle on quadratus rotates thighc;

intertrochanteric femoris (L4, L5, steadies
crest of femur S1) femoral head in
and area inferior acetabulum
to it
 Piriformis
&
obturator internus
Piriformis syndrome:
• Is a neuromuscular disorder that occurs when the sciatic nerve is
compressed by the piriformis muscle
• Causes pain, tingling and numbness in the buttocks and along the path of
the sciatic nerve descending down the lower thigh and into the leg
• The syndrome may be due to anatomical variations in the muscle-nerve
relationship, or from overuse or strain.
 Superior gluteal artery

From the posterior division of the

internal iliac a.
 enters gluteal region through
greater sciatic foramen, superior
to piriformis;
 divides into superficial and deep
branches;
 Superficial branch supplying
gluteus maximus
 Deep branch: runs between
gluteus medius and minimus
supplying both muscles & Tenser
Fascia Lata
 Superior gluteal nerve
 Arises from posterior divisions of anterior rami of L4-S1 of sacral
plexus
 Leaves pelvis through greater sciatic foramen superior to piriformis;
runs between gluteus medius and minimus
 Innervates gluteus medius, gluteus minimus, and tensor fasciae
latae
 Inferior gluteal artery

 The largest of the 2 terminal branches

of the anterior division of the internal
iliac a.

 Enters gluteal region through greater

sciatic foramen, inferior to piriformis;

 Descends on medial side of sciatic

nerve; anastomoses with superior
gluteal artery and participates in
cruciate anastomosis of thigh

 Supply Gluteus maximus, obturator

internus, quadratus femoris, and
superior parts of hamstrings
 Inferior gluteal nerve
 Arises from posterior divisions of anterior rami of L5-S2 of sacral
plexus
 Leaves pelvis through greater sciatic foramen inferior to piriformis;
 Lies superficial to the sciatic nerve
 After a short course it divides into many branches which enter the
deep surface of G maximus supplying it
 Posterior cutaneous nerve of the thigh
 Arises from anterior and posterior divisions of anterior rami of
S1-S3of sacral plexus
 Leaves pelvis through greater sciatic foramen inferior to
piriformis; runs deep to gluteus maximus; emerges from its
inferior border; descends in posterior thigh deep to fascia lata
 Supplies
 skin of buttock through inferior clunial branches
 skin over posterior aspect of thigh and calf;
 lateral perineum, upper medial thigh via perineal branch
 Sciatic nerve
 anterior and posterior divisions of
anterior rami of L4-S3 Sacral plexus
 Leaves pelvis through greater sciatic
foramen inferior to piriformis; enters
gluteal region; descends deep to
biceps femoris; bifurcates into tibial
and common fibular nerves at apex of
popliteal fossa
 Lies midway between the ischial
tuberosity & greater trochanter
 Supplies no muscles in gluteal region;
supplies all muscles in posterior
compartment of thigh
 Components:
1-Tibial part (L4,5,S1,2,3 anterior)
2-Common peroneal part (L4,5,S1,2
posterior)
 Intragluteal Injections

 Injections into the buttock are safe only in the

 superolateral quadrant of the buttock or
 superior to a line extending from the PSIS to the superior border of
the greater trochanter

Complications of improper technique include

 nerve injury,
 Hematoma
 abscess formation.
 Nerve to obturator internus
 Arises from posterior divisions of anterior rami of L5-S2 sacral
plexus
 Enters gluteal region through greater sciatic foramen inferior to
piriformis; descends posterior to ischial spine; lateral to the
pudendal vessels enters lesser sciatic foramen;
 Supplies superior gemellus and obturator internus
Nerve to quadratus femoris

 Arises from anterior divisions

of anterior rami of L4,L5,S1
Sacral plexus
 Leaves pelvis through greater
sciatic foramen deep to sciatic
nerve
 Descends anterior to obturator
internus & gemelli & Enters
quadratus femoris at its anterior
surface
 Innervates hip joint, inferior
gemellus, and quadratus
femoris
 Internal pudendal artery

 Arises from the anterior division of internal iliac artery

 Enters gluteal region through greater sciatic foramen; descends
posterior to ischial spine; (between the pudendal n. & n. to OI)
 enters perineum through lesser sciatic foramen
 Supply External genitalia and muscles in the perineal region; does
not supply gluteal region
 Pudendal nerve
 Arises from anterior divisions of anterior rami of S2-S4 sacral plexus
 Enters gluteal region through greater sciatic foramen inferior to
piriformis; descends posterior to sacrospinous ligament; enters
perineum through lesser sciatic foramen
 Supplies most innervation to the perineum; supplies no structures in
gluteal region
 Butt enhancement
(Gluteal augmentation)
Butt implants
(By implanting silicon
Butt grafts
between fat & muscles)
(Transfer fat from abdomen &
flanks to the butt)
 Arterial anastomosis

 Anastomosis around the ASIS:

Connect the iliac arteries to the femoral & profunda arteries

1- Iliac branch of iliolumbar artery (internal internal iliac)

2- Deep circumflex iliac a. (external iliac)

3- Superficial circumflex iliac a. (femoral)

4- Ascending branch of LCF (profunda femoris)

Cruciate anastomosis
 Connects the internal iliac a. to the
profunda femoris

 Lies in the region of quadratus femoris

 Formed by:

Profunda femoris
1- Transverse branch of LCF

2- Transverse branch of MCF

3- Ascending branch of 1st perforating a.

4-Descending branch of inferior gluteal a.

(internal iliac)
 References

 Moore, Essential Clinical Anatomy, 4th ed.

 Clinically Oriented Anatomy - 6th Ed
 Gray's Anatomy - 40th Ed
 Prof. Dr. Nawfal Al- Hadithi. Anatomy of the
Lower Limb