1. Dr. Fadel Naim Orthopedic Surgeon IUG
The Thigh II
Dr. Fadel Naim
Orthopedic Surgeon
IUG

2. CONTENTS OF THE MEDIAL FASCIAL COMPARTMENT OF THE THIGH
Muscles:
Gracilis
Adductor longus
Adductor brevis
Adductor magnus
Obturator externus
• Blood supply:
Profunda femoris artery
Obturator artery
• Nerve supply:
Obturator nerve

4. Gracilis Long and strap like
Lies on the medial side of the thigh and the knee
Origin:
The outer surface of the inferior ramus of the pubis
The ramus of the ischium
Insertion:
The fibers pass downward along the medial side of the thigh
Attached to the upper part of the medial surface of the shaft of the tibia
Close to that of the sartorius and the semitendinosus muscles.
Nerve supply:
Obturator nerve.
• Action:
Adducts the thigh at the hip joint
Flexes the leg at the knee joint

5. Adductor Longus Triangular
The most anterior of the three adductor muscles
Origin:
From the front of the body of the pubis below and medial to the pubic tubercle
Insertion:
The muscle fibers diverge as they pass downward and laterally
Attached to the linea aspera
Nerve supply:
Obturator nerve.
• Action:
Adducts the thigh at the hip joint
Assists in lateral rotation

6. Adductor Brevis
lies posterior to the pectineus and the adductor longus.
Origin:
From the outer surface of the inferior ramus of the pubis
Insertion:
The muscle fibers diverge as they pass downward and laterally
attached to the linea aspera
Nerve supply:
Obturator nerve.
Action:
Adducts the thigh at the hip joint
Assists in lateral rotation

7. Adductor Magnus A large, triangular muscle
Consisting of adductor and hamstring portions
Origin:
From the outer surface of the inferior ramus of the pubis
From the ramus of the ischium and the ischial tuberosity.
Insertion:
In the adductor portion:
The muscle fibers diverge as they pass downward and laterally
Attached to the posterior surface of the shaft of the femur.
In the hamstring portion
The fibers that arise from the ischial tuberosity are inserted below on the adductor tubercle on the medial condyle of the femur.
Nerve supply:
The adductor portion: the obturator nerve
The hamstring portion: the sciatic nerve.
Action:
The adductor portion
Adducts the thigh at the hip joint
Assists in lateral rotation.
The hamstring portion
Extends the thigh at the hip joint.

8. Adductor Hiatus A gap is in the attachment of this muscle to the femur
Permits the femoral vessels to pass from the adductor canal downward into the popliteal space

9. Obturator Externus A deeply placed, triangular muscle. Origin:
From the outer surface of the obturator membrane
The pubic and ischial rami.
• Insertion:
The muscle fibers converge as they pass laterally at first below and then behind the hip joint
Inserted onto the medial surface of the greater trochanter.
• Nerve supply:
Obturator nerve.
• Action:
Laterally rotates the thigh at the hip joint.

10. Origin Insertion Nerve Supply Nerve Roots Action Muscle Gracilis
Inferior ramus of pubis, ramus of ischium
Upper part of shaft of tibia on medial surface
Obturator nerve
L2, 3L2, 3, 4L2, 3, 4
Adducts thigh at hip joint; flexes leg at knee joint
Adductor longus
Body of pubis, medial to pubic tubercle
Posterior surface of shaft of femur (linea aspera)
Adducts thigh at hip joint and assists in lateral rotation
Adductor brevis
Inferior ramus of pubis
Adductor magnus
Inferior ramus of pubis, ramus of ischium, ischial tuberosity
Posterior surface of shaft of femur, adductor tubercle of femur
Adductor portion: obturator nerve Hamstring portion: sciatic nerve
L2,3 & 4
Adducts thigh at hip joint and assists in lateral rotation; hamstring portion extends thigh at hip join
Obturator externus
Outer surface of obturator membrane and pubic and ischial rami
Medial surface of greater trochanter
L3, 4
Laterally rotates thigh at hip joint

11. Blood Supply of the Medial Fascial Compartment of the Thigh
Profunda femoris artery
A large artery that arises from the lateral side of the femoral artery in the femoral triangle, about 1.5 in. (4 cm) below the inguinal ligament
It descends in the interval between the adductor longus and adductor brevis and then lies on the adductor magnus
Ends as the fourth perforating artery

12. Branches Profunda Femoris Artery
Medial femoral circumflex artery:
This passes backward between the muscles that form the floor of the femoral triangle
Gives off muscular branches in the medial fascial compartment of the thigh
It takes part in the formation of the cruciate anastomosis.
Lateral femoral circumflex artery:
This passes laterally between the terminal branches of the femoral nerve
It breaks up into branches that supply the muscles of the region
Takes part in the formation of the cruciate anastomosis.
Four perforating arteries:
Three of these arise as branches of the profunda femoris artery
The fourth perforating artery is the terminal part of the profunda artery
The perforating arteries run backward, piercing the various muscle layers as they go.
Terminate by anastomosing with:
One another
The inferior gluteal artery
The circumflex femoral arteries
The muscular branches of the popliteal artery

13. DR FADEL NAIM
IUG

14. Profunda Femoris Vein
The profunda femoris vein receives tributaries that correspond to the branches of the artery.
It drains into the femoral vein

15. Obturator Artery A branch of the internal iliac artery
Passes forward on the lateral wall of the pelvis
Accompanies the obturator nerve through the obturator canal
On entering the medial fascial compartment of the thigh, it divides into medial and lateral branches, which pass around the margin of the outer surface of the obturator membrane.
It gives off muscular branches and an articular branch to the hip joint.

16. Obturator Vein
The obturator vein receives tributaries that correspond to the branches of the artery
It drains into the internal iliac vein

17. ADDUCTOR MUSCLES AND CEREBRAL PALSY
In patients with cerebral palsy who have marked spasticity of the adductor group of muscles
It is common practice to
Perform a tenotomy of the adductor longus tendon
Divide the anterior division of the obturator nerve.
In addition, in some severe cases the posterior division of the obturator nerve is crushed.
This operation overcomes the spasm of the adductor group of muscles and permits slow recovery of the muscles supplied by the posterior division of the obturator nerve.

18. Superficial Veins
Many small veins curve around the medial and lateral aspects of the thigh and ultimately drain into the great saphenous vein
Veins from the lower part of the back of the thigh join the small saphenous vein in the popliteal fossa.

19. Lymph Vessels
Lymph from the skin and superficial fascia on the back of the thigh drains upward and forward into the vertical group of superficial inguinal lymph nodes

20. CONTENTS OF THE POSTERIOR FASCIAL COMPARTMENT OF THE THIGH
Muscles:
Biceps femoris
Semitendinosus
Semimembranosus
a small part of the adductor magnus (hamstring muscles).
Blood supply:
Branches of the profunda femoris artery.
Nerve supply:
Sciatic nerve.

22. Biceps Femoris Origin: Insertion: Nerve supply: Action: The long head
The ischial tuberosity
The short head
The linea aspera
The lateral supracondylar ridge of the shaft of the femur.
Insertion:
The two heads unite just above the knee joint
The common tendon is inserted into the head of the fibula.
Nerve supply:
The long head is supplied by the tibial part of the sciatic
The short head is supplied by the common peroneal part of the sciatic.
Action:
Flexes and laterally rotates the leg at the knee joint
The long head also extends the thigh at the hip joint.

23. Semitendinosus Origin: Insertion: Nerve supply: Action:
From the ischial tuberosity
Insertion:
By a long tendon into the upper part of the medial surface of the shaft of the tibia.
Nerve supply:
The tibial portion of the sciatic.
Action:
Flexes and medially rotates the leg at the knee joint
Extends the thigh at the hip joint.

24. Semimembranosus Origin: Insertion: Nerve supply: Action:
From the ischial tuberosity
Insertion:
Into the posteromedial surface of the medial condyle of the tibia.
The oblique popliteal ligament:
A fibrous expansion upward and laterally, which reinforces the capsule on the back of the knee joint
Nerve supply:
The tibial portion of the sciatic.
Action:
Flexes and medially rotates the leg at the knee joint
It also extends the thigh at the hip joint.

25. Pes Anserinus

26. Adductor Magnus (Hamstring Portion)
Origin:
From the outer surface of the inferior ramus of the pubis
from the ramus of the ischium and the ischial tuberosity.
Insertion:
In the hamstring portion
the fibers that arise from the ischial tuberosity are inserted below on the adductor tubercle on the medial condyle of the femur
Nerve supply:
The tibial portion of the sciatic
Action:
Extends the thigh at the hip joint.

28. 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
The profunda femoris vein drains the greater part of the blood from the compartment

29. Hip Joint
The articulation between the hemispherical head of the femur and the cup-shaped acetabulum of the hip bone
The articular surface of the acetabulum is horseshoe shaped and is deficient inferiorly at the acetabular notch.
The cavity of the acetabulum is deepened by the presence of a fibrocartilaginous rim called the acetabular labrum.
The labrum bridges across the acetabular notch and is here called the transverse acetabular ligament
The articular surfaces are covered with hyaline cartilage.
The hip joint is a synovial ball-and-socket joint.

31. CAPSULE The capsule encloses the joint
Attached to the acetabular labrum medially
Laterally
To the intertrochanteric line of the femur in front
some of its fibers, accompanied by blood vessels, are reflected upward along the neck as bands called retinacula.
These blood vessels supply the head and neck of the femur.
Halfway along the posterior aspect of the neck of the bone behind.

33. LIGAMENTS The iliofemoral ligament:
A strong, inverted v-shaped ligament
Its base is attached to the anterior inferior iliac spine above
Below, the two limbs of the Y are attached to the upper and lower parts of the intertrochanteric line of the femur.
Prevents overextension during standing.

34. LIGAMENTS The pubofemoral ligament Triangular
The base of the ligament is attached to the superior ramus of the pubis
The apex is attached below to the lower part of the intertrochanteric line.
This ligament limits extension and abduction.

35. LIGAMENTS The ischiofemoral ligament Spiral shaped
Attached to the body of the ischium near the acetabular margin
The fibers pass upward and laterally
Attached to the greater trochanter
This ligament limits extension.

36. LIGAMENTS The transverse acetabular ligament
formed by the acetabular labrum as it bridges the acetabular notch
converts the notch into a tunnel through which the blood vessels and nerves enter the joint.
The ligament of the head of the femur
flat and triangular
It is attached by its apex to the pit on the head of the femur (fovea capitis)
its base to the transverse ligament and the margins of the acetabular notch.
It lies within the joint and is ensheathed by synovial membrane

38. SYNOVIAL MEMBRANE The synovial membrane lines the capsule
Attached to the margins of the articular surfaces
It covers the portion of the neck of the femur that lies within the capsule.
It ensheathes the ligament of the head of the femur
Covers the pad of fat contained in the acetabular fossa

39. SYNOVIAL MEMBRANE
A pouch of synovial membrane frequently protrudes through the gap in the anterior wall of the capsule, between the femoral and iliofemoral ligaments, and forms bursa beneath the psoas tendon

40. NERVE SUPPLY Femoral nerve Obturator nerve Sciatic nerve
The nerve to quadratus femoris

41. Movements Of The Hip Joint
A wide range of movement, but less so the shoulder joint
Some of the movement has been scarified to provide strength and stability.
The strength of the joint depends largely on:
The shape of the bones taking part in the articulation
The strong ligaments.
When the knee is flexed
Flexion is limited by
the anterior surface of the thigh coming into contact with the anterior abdominal wall.
When the knee is extended
the tension of the hamstring group of muscles.

42. Extension is limited by the tension of
The iliofemoral ligament
Pubofemoral ligament
Ischiofemoral ligament
Abduction is limited by the tension of
The pubofemoral ligament
Adduction is limited by
Contact with the opposite limb
The tension in the ligament of the head of the femur
Lateral rotation is limited by
The tension in the iliofemoral ligament
Medial rotation is limited by
The ischiofemoral ligament

43. Movements Of The Hip Joint
Flexion
Extension
Abduction
Adduction
Lateral rotation.
Medial rotation.
Circumduction is a combination of the previous movements.
The extensor group of muscles is more powerful than the flexor group
The lateral rotators are more powerful than the medial rotators.

45. Important Relations Anteriorly: Posteriorly: Superiorly: Inferiorly:
Iliopsoas
Pectineus
Rectus femoris muscles.
The iliopsoas and pectineus separate the femoral Vessels and nerve from the joint
Posteriorly:
The obturator internus
the gemelli
The quadratus femoris muscles separate the joint from the sciatic nerve
Superiorly:
Piriformis
gluteus minimus
Inferiorly:
Obturator externus tendon

46. REFERRED PAIN FROM THE HIP JOINT
The femoral nerve not only supplies the hip joint but also supplies the skin of the front and medial side of the thigh.
Pain originating in the hip joint may be referred to the front and medial side of the thigh
The posterior division of the obturator nerve supplies both the hip and knee joints.
Hip joint disease sometimes gives rise to pain in the knee joint.

47. CONGENITAL DISLOCATION OF THE HIP
The stability of the hip joint depends on the ball-an dsocket arrangement of the articular surfaces and the strong ligaments
In congenital dislocation of the hip the upper lip of the acetabulum fails to develop adequately
The head of the femur rides up out of the acetabulum onto the gluteal surface of the ilium.

48. Developmental encompasses embryonic, fetal and infantile periods
Previously known as congenital dislocation of the hip implying a condition that existed at birth
Developmental encompasses embryonic, fetal and infantile periods
Includes congenital dislocation and developmental hip problems including:
Subluxation
Dislocation
Dysplasia

51. TRAUMATIC DISLOCATION OF THE HIP
Rare because of its strength
Usually caused by motor vehicle accidents
Joint is flexed and adducted.
The head of the femur is displaced posteriorly out of the acetabulum
Rest on the gluteal surface of the ilium (posterior dislocation)
The sciatic nerve is prone to injury in posterior dislocations

52. TRAUMATIC DISLOCATION OF THE HIP

53. Hip Joint Stability Normal Gait
The stability of the hip joint when a person stands on one leg with the foot of the opposite leg raised above the ground depends on three factors:
The gluteus medius and minimus must be functioning normally.
The head of the femur must be located normally within the acetabulum.
The neck of the femur must be intact and must have a normal angle with the shaft of the femur.

54. Hip Joint Stability Normal Gait
A positive trendelenburg's sign
If anyone of these factors is defective, then the pelvis will sink downward on the opposite, unsupported side.
Normally, when walking, a person alternately contracts the gluteus medius and minimus
By this means he or she is able to raise the pelvis allowing the leg to be flexed at the hip joint and moved forward
The leg is raised clear of the ground before it is thrust forward in taking the forward step.

55. Dipping and Waddling Gait
A patient with a right-sided congenital dislocation of the hip, when asked to stand on the right leg and raise the opposite leg clear of the ground, will exhibit a positive Trendelenburg's sign, and the unsupported side of the pelvis will sink below the horizontal
If the patient is asked to walk, he or she will show the characteristic "dipping" gait.
In patients with bilateral congenital dislocation of the hip, the gait is typically "waddling“ in nature.

56. ARTHRITIS OF THE HIP JOINT
A patient with an inflamed hip joint will place the femur in the position that gives minimum discomfort
The position in which the joint cavity has the greatest capacity to contain the increased amount of synovial fluid secreted.
The hip joint is partially:
Flexed
Abducted
Externally rotated.

57. Osteoarthritis Of the Hip Joint Coxarthrosis
The most common disease of the hip joint in the adult
Causes:
Pain
In the hip joint itself or referred to the knee
(the obturator nerve supplies both joints)
Stiffness
Caused by the pain and reflex spasm of the surrounding muscles.
Deformity
Produced initially by muscle spasm and later by muscle contracture.
Flexion
Adduction
External rotation