Medial (Adductor) Compartment of the Thigh PDF

Kamal Abouzaid, MD, PhD Lower Limb Medial (adductor) compartment of the thigh Kamal Abouzaid, MD, PhD Associate Profess...

Kamal Abouzaid, MD, PhD Lower Limb Medial (adductor) compartment of the thigh Kamal Abouzaid, MD, PhD Associate Professor, Preclinical Sciences (Anatomy) William Carey University College of Osteopathic Medicine This material is for classroom use only. It may not be reproduced or distributed. Kamal Abouzaid, MD, PhD Lower Limb Medial compartment of the thigh Learning Objectives 1. Describe the general attachments, innervations, and actions of the muscles of the medial compartment. 2. Why gracilis is preferred as muscle graft? 3. Describe adductor longus strain. 4. Why adductor magnus is described as a composite muscle? 5. Describe the course of the obturator nerve, and artery. 6. Describe the adductor canal and enumerate its content. Why it is considered as a continuation of the apex of the femoral triangle. Describe the adductor canal block. 7. How obturator neurectomy and adductor tenotomy could help patients with intractable spastic paraplegia?  Kamal Abouzaid, MD, PhD Lower Limb Muscles of the medial compartment of the thigh Pes anserinus Sartorius Gracilis Semitendinosus Gracilis: The most superficial muscle of the medial compartment Arises from the inferior pubic ramus and the adjoining ischial ramus. Inserts into the upper part of the medial surface of shaft of tibia behind the Sartorius (Pes anserinus) The gracilis receives segmental blood supply from the medial circumflex, Nerve supply: obturator nerve. profunda femoris, and femoral artery (in succession distally). A gracilis muscle Action: adducts the hip joint, and flexes the flap (transplant) can be used in perineal reconstructive surgery (or any knee joint, and medially rotate the leg. damaged muscle).  Kamal Abouzaid, MD, PhD Lower Limb Muscles of the medial compartment of the thigh Adductor longus Arises from a circular area on the body of the pubis by a strong round tendon. The muscle flattened out and insert into the middle third of linea aspera. Nerve supply: obturator nerve. Action: powerful adductor of thigh. Strains of the origin of the adductor longus may occur in horseback riders and produce pain (rider’s strain). Calcification of the tendon of origin of the adductor muscles are sometimes wrongly called “riders’ bones.”  Kamal Abouzaid, MD, PhD Lower Limb Muscles of the medial compartment of the thigh Adductor brevis Arises from the body and inferior ramus of pubis deep to pectineus and adductor longus. The muscle widens in a triangular fashion to insert into the upper part of linea aspera. Nerve supply: obturator nerve. Action: adducts the thigh at hip joint and helps in flexion of the hip joint.  Kamal Abouzaid, MD, PhD Lower Limb Muscles of the medial compartment of the thigh Adductor magnus Is the largest and deepest muscle of the medial compartment. It is a composite muscle formed by fusion of adductor and hamstring masses, each with its own nerve supply. The adductor part of adductor magnus: Arises from the ischiopubic ramus. Inserts into the medial supracondylar line, linea aspera and up to the gluteal tubrosity. Nerve supply: obturator nerve. Action: adducts the thigh.  Kamal Abouzaid, MD, PhD Lower Limb Muscles of the medial compartment of the thigh Adductor magnus The hamstring part of adductor magnus: Arises from the ischial tuberosity, and the fibers run vertically downwards to a tendinous attachment to the adductor tubercle on the medial condyle of the femur, and with an expansion to the medial supracondylar line. Nerve supply: Sciatic nerve (tibial division). Action: Extension of the hip. A large circular gap between the adductor and hamstring parts, the adductor hiatus, provides passage for the femoral vessels. Along the linea aspera attachment there are four openings. The lowest one is for profunda femoris vessels, and the others for their perforating branches.  Kamal Abouzaid, MD, PhD Lower Limb Muscles of the medial compartment of the thigh Obturator externus Arises from the whole of the obturator membrane and from the anterior bony margin around the obturator foramen. The muscle fibers converge and pass laterally, posterior to the neck of femur to insert into a deep pit on the medial surface of the greater trochanter, the trochanteric fossa. Nerve supply: by the posterior division of the obturator nerve. Action: Lateral rotator of the femur at the hip joint.  Kamal Abouzaid, MD, PhD Lower Limb Obturator artery Emerges from the obturator foramen with the nerve. Divides into anterior and posterior branches that encircle the foramen between the obturator externus and the membrane. They anastomose with each other and with the medial circumflex femoral artery. The posterior branch gives off an articular twig to the hip joint. It enters the acetabular notch and run in the ligament of the head of femur to supply a small area around the pit of the head (important source of blood supply to the femoral head epiphysis in children).  Kamal Abouzaid, MD, PhD Lower Limb Innervation of the medial compartment of the thigh Obturator nerve Originates from the lumbar plexus from the anterior divisions of the ventral rami of L2,3,4. It enters the thigh by passing through the obturator foramen. In the obturator notch it divides into anterior and posterior divisions. The Posterior division passes through the obturator externus, then descends posterior to adductor brevis and on the anterior surface of adductor magnus. It supplies obturator externus, adductor brevis (if not supplied by the anterior division) and the adductor part of adductor magnus. Its terminal branch descends with the femoral artery through the adductor hiatus to supply the knee joint. The anterior division descends anterior to the adductor brevis, and deep to pectineus and adductor longus and goes on to supply gracilis. It also gives off a sensory branch to the hip joint and a branch to the subsurtorial plexus to supply the medial aspect of the thigh. A disease in the hip joint may cause referred pain in the knee and on the medial aspect of the thigh.  Kamal Abouzaid, MD, PhD Lower Limb Adductor tenotomy and selective obturator neurectomy for the treatment of spastic paraplegia In patients with spastic paraplegia, it is difficult to maintain good perineal hygiene because of the scissoring effects of legs. Spasm of the adductors of the thigh in certain intractable cases of spastic paraplegia can be relieved surgically by division of the obturator nerve. This could be combined with adductor tenotomy. Congenital dislocation of the hip joint: If an adductor contracture limits abduction (and reduction of the dislocated hip), percutaneous adductor tenotomy (of adductor longus) could be performed before close (or open) reduction of the hip joint. Percutaneous Adductor Tenotomy  Kamal Abouzaid, MD, PhD Lower Limb The adductor canal Also known as subsartorial or Hunter’s canal. It is a gutter-shaped groove between vastus medialis and the adductor muscles, below the apex of the femoral triangle. The roof is by fascia which contains meshes the subsartorial plexus of nerves. Sartoius lies over on the fascial roof. The subsartorial plexus receives small branches from the medial cutaneous nerve, the saphenous nerve, and the anterior division of the obturator nerve.  Kamal Abouzaid, MD, PhD Lower Limb The adductor canal Content: 1. Femoral artery: Begins at the apex of the femoral triangle and leaves the canal at the adductor hiatus. Just above the adductor hiatus it gives off the descending genicular artery. 2. The femoral vein ascends posterior to the artery until in the femoral triangle it comes to lie on the medial side of the artery. 3. The saphenous nerve crosses the artery from lateral to medial sides. It leaves the canal by piercing the fascial roof, pierces the fascia lata and descends posterior to the great saphenous vein. 4. Nerve to vastus medialis lies lateral to the femoral artery. 5. The terminal part of the posterior division of the obturator nerve accompanies the femoral and popliteal arteries to supply the knee joint  Kamal Abouzaid, MD, PhD Lower Limb Adductor canal block Under the guidance of ultrasonography, the adductor canal can be easily visualized at the mid-thigh level, allowing performance of adductor canal block (ACB). ACB has been successfully used for postoperative pain control after knee surgery. The adductor canal serve as a conduit for saphenous nerve, possibly including the vastus medialis nerve, medial femoral cutaneous nerve, articular branches from the obturator nerve. Thus, the sensory block includes the medial and anterior aspects of the knee from the superior pole of the patella to the proximal tibia.