Following a car accident in which the patient received a deep laceration on the medial side of his right knee, the patient notices numbness along the lateral side of his right leg and foot. He has no motor deficit. The nerve which appears to have been injured is the: femoral nerve saphenous nerve sural nerve superficial fibular nerve

Competency of venous valves in a patient with severe crural varicose veins was tested as follows: The superficial veins were emptied by elevating the limb and then they were compressed with a band just below the saphenous opening in the proximal thigh. When the patient quickly stood up, filling of the superficial veins took more than 30 seconds. The delayed filling of the superficial veins demonstrates that the valves of the: deep (central) veins are competent deep (central) veins are incompetent perforating veins are competent perforating veins are incompetent superificial veins are competent

lower limb Gluteal region DR.RAJ ANATOMY DEPT, WUSM

Gluteal Region The gluteal region lies posterolateral to the bony pelvis and proximal end of the femur. Muscles in the region mainly abduct, extend, and laterally rotate the femur relative to the pelvic bone.

Ligaments of the Gluteal Region Sacrotuberous Ligament: sacrotuberous ligament connects the back of the sacrum to the ischial tuberosity Sacrospinous Ligament: sacrospinous ligament connects the back of the sacrum to the spine of the ischium.

Foramina of the Gluteal Region Greater Sciatic Foramen:The greater sciatic foramen is formed by the greater sciatic notch of the hip bone and the sacrotuberous and sacrospinous ligaments. It provides an exit from the pelvis into the gluteal region.

Structures passing through greater sciatic foraman Superior gluteal artery and nerve Superior gluteal artery Piriformis Inferior gluteal artery and nerve Nerve to quadratus femoris Nerve to obturator internus Pudendal nerve Internal pudendal artery and vein Sciatic nerve Posterior cutaneous nerve of thigh

Lesser Sciatic Foramen: Formed by the lesser sciatic notch of the hip bone and the sacrotuberous and sacrospinous ligaments. It provides an entrance into the perineum from the gluteal region.

Structures passing through lesser sciatic foramen Tendon of obturator internus Nerve to obturator internus Pudendal nerve Internal pudendal artery and vein

Nerves of the Gluteal Region Sacral Plexus: The sacral plexus lies on the posterior pelvic wall in front of the piriformis muscle . It is formed from the anterior rami of the lumbar nerves and the anterior rami of the sacral nerves.

Posterior wall of the pelvis

Branches Branches to the lower limb that leave the pelvis through the greater sciatic foramen . 1. Sciatic (L4, L5, S1, S2, S3): Articular branches to hip joint and muscular branches. It is the largest nerve in the body and consists of the tibial and common peroneal nerves bound together with fascia. Innervates all muscles in the posterior compartment of the thigh that flex the knee and all muscles that work the ankle and foot. llmusclein leg and foot

2. Superior gluteal (L4, L5, S1) : Gluteus medius and gluteus minimus muscles 3. Inferior gluteal (L5, S1, S2): Gluteus maximus

4. Nerve to obturator internus ( L5, S1, S2) : Obturator internus and superior gemellus muscles 5. Nerve to quadratus femoris (L4, L5, S1) : Quadratus femoris and inferior gemellus muscles 6. Posterior cutaneous nerve of the thigh(S2, S3) : Cutaneous branches to buttock and uppermost medial and posterior surfaces of thigh.

Branches to the pelvic muscles, pelvic viscera, and perineum: 1. Pudendal (S2, S3, S4) : Structures in perineum: sensory to genitalia; muscular branches to perineal muscles, external urethral sphincter, and external anal sphincter 2. Nerve to piriformis (S1, S2) : Piriformis muscle

Muscles of the Gluteal Region Muscles of the gluteal region are mainly in two groups: Superficial group of larger muscles: Gluteus minimus, gluteus medius, and gluteus maximus-and tensor fasciae latae. 2. Deep group of small muscles: Piriformis, obturator internus, gemellus superior, gemellus inferior, and quadratus femoris.

Muscles of Gluteal Region (Superficial group) Extensor of hip Gluteus maximus (also helps in lateral rotation) Abductors of hip (help in Medial rotation) Gluteus medius Gluteus minimus Tensor Fascia lata (also stabilizes knee in extension) Function of all 3 Contract to prevent sagging of unsupported side of hip during locomotion, enabling opposite foot to swing through (e.g., Trendelenburg test)

Gluteus maximus Origin : Outer surface of ilium, sacrum, coccyx, sacrotuberous ligament Insertion :Iliotibial tract and gluteal tuberosity of femur N. supply: Inferior gluteal nerve Action :Extends and laterally rotates hip joint

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Gluteus medius Origin : Outer surface of ilium Insertion :Lateral surface of greater trochanter of femur N. supply: Superior gluteal nerve Action :Abducts thigh at hip joint; tilts pelvis when walking to permit opposite leg to clear ground

Gluteus minimus Origin : Outer surface of ilium Insertion :Anterior surface of greater trochanter of femur N. supply: Superior gluteal nerve Action :Abducts thigh at hip joint; tilts pelvis when walking to permit opposite leg to clear ground

Positive Trendelenburg's sign If right gluteus medius and minimus muscles are paralyzed, the unsupported left side of the pelvis falls (sags) instead of rising; normally, the pelvis rises.

Tensor fasciae latae Origin : Iliac crest Insertion :Iliotibial tract N. supply: Superior gluteal nerve Action :Assists gluteus maximus in extending the knee joint

Deep group of small muscles Lateral Rotators of the Hip. Small Muscles Mostly attach near or on greater trochanter All but one innervated by named nerves specific to one or two of them The exception is the obturator externus – innervated by posterior branch of obturator n.

PYRIFORMIS N. supply: 1st & 2nd Sacral nerves Origin : Anterior surface of sacrum; sacrotuberous ligament Insertion : Upper border of Greater trochanter of femur N. supply: 1st & 2nd Sacral nerves Action : Lateral rotation of thigh at hip joint

OBTURATOR INTERNUS Obturator membrane Greater trochanter of femur Origin : Inner surface of Obturator membrane Insertion : Upper border of Greater trochanter of femur N. supply: Nerve to obturator internus Action : Lateral rotation of thigh at hip joint

SUPERIOR GEMELLUS N. supply: Nerve to obturator internus Origin : Spine of ischium Insertion : Upper border of Greater trochanter of femur N. supply: Nerve to obturator internus Action : Lateral rotation of thigh at hip joint

INFERIOR GEMELLUS Greater trochanter of femur Origin : Ischial tuberosity Insertion : Upper border of Greater trochanter of femur N. supply: Nerve to quadratus femoris (L5, S1) Action : Lateral rotation of thigh at hip joint

QUADRATUS FEMORIS ischial tuberosity femur Origin : Lateral border of ischial tuberosity Insertion : Quadrate tubercle of femur N. supply: Nerve to quadratus femoris (L5, S1) Action : Lateral rotation of thigh at hip joint

Intramuscular injections The safest place to inject is the upper outer quadrant of either gluteal region.

Arteries of the Gluteal Region 1. Superior Gluteal Artery 2. Inferior Gluteal Artery

Posterior compartment of thigh Muscles: Biceps femoris, semitendinosus, semimembranosus, and a small part of the adductor magnus (hamstring muscles) Blood supply: Branches of the profunda femoris artery Nerve supply: Sciatic Nerve

Biceps femoris Origin : Long head: Ischial tuberosity Short head: linea aspera, lateral supracondylar ridge of shaft of femur Insertion : Head of fibula N. supply: Long head: tibial portion of sciatic nerve Short head: common peroneal portion of sciatic nerve Action : Flexes leg at knee joint; long head also extends thigh at hip joint

Semitendinosus N. supply: Tibial portion of sciatic nerve Origin : Ischial tuberosity Insertion : Upper part of medial surface of shaft of tibia N. supply: Tibial portion of sciatic nerve Action : Flexes leg at knee joint; extends thigh at hip joint

Semimembranosus N. supply: Tibial portion of sciatic nerve Origin : Ischial tuberosity Insertion : Medial condyle of tibia N. supply: Tibial portion of sciatic nerve Action : Flexes leg at knee joint; extends thigh at hip joint

Adductor magnus (hamstring portion) Origin : Ischial tuberosity Insertion : Adductor tubercle of femur N. supply: Tibial portion of sciatic nerve Action : Extends thigh at hip joint

Posterior compartment Hamstrings Together extend hip (except short head of biceps femoris) and flex knee (except add mag)

Blood Supply of the Posterior Compartment of the Thigh The four perforating branches of the profunda femoris artery provide a rich blood supply to this compartment