Hip and Gluteal Region PDF

©  The Hip and Gluteal Region Dr. Sean McWatt, PhD [email protected] Mehau Kulyk / SPL / Getty Learning Outcomes By the end of this lesson, you will be able to… Identify and describe the bones rel...

©  The Hip and Gluteal Region Dr. Sean McWatt, PhD [email protected] Mehau Kulyk / SPL / Getty Learning Outcomes By the end of this lesson, you will be able to… Identify and describe the bones related to the hip joint and the ligaments that stabilize it Explain the basic movements that occur at the hip Identify the intrinsic muscles of the hip and gluteal region, explain their innervations, and describe their functions Predict functional implications of nervous and musculoskeletal injuries to the hip and gluteal region Regions of the Lower Limb Gluteal region Hip Thigh As we did in the upper limb Anterior, medial, and posterior compartments unit, we will run through the lower limb from proximal to distal, covering the important Knee anatomical structures and Popliteal fossa relationships along the way Leg Anterior, posterior, and lateral compartments Foot Dorsal surface Plantar surface Drake, Gray’s Anatomy for Students, 2nd Ed., Copyright © 2009 by Churchill Livingstone Bones of the Lower Limb Sacroiliac joint Coxal bone Ilium, ischium, pubis Hip joint The coxal (hip) bone is made up of three Pubic symphysis separate bones that fuse to become one. The left and right coxal bones articulate Femur at the pubic symphysis and sacroiliac joints to form the pelvic girdle. The coxal bone articulates with the Knee joint Patella femur to form the hip joint. The femur articulates with the patella Tibia and tibia to form the knee joint. The non- Fibula weightbearing fibula also articulates with the tibia there. Ankle joint Tarsal bones The tibia and fibula articulate with each Bones of the other and the tarsal bones at the ankle joint. Joints of the foot and digits foot and digits Anterior view Gilroy, Anatomy: An Essential Textbook, Copyright © 2013 by Thieme Bones, Joints, and Ligaments Bones of the Hip and Pelvis The left and right coxal bones articulate with the sacrum, posteriorly (at the sacroiliac joints), and with each other, anteriorly (at the pubic symphysis), forming the pelvic girdle The coccyx articulates with Coxal bone Ilium, ischium, pubis the inferior aspect of the sacrum. Sacrum Five fused vertebrae Coccyx Three-five fused vertebrae The femur articulates with the coxal Pubic symphysis bone to form Femur the hip joint Head, neck, greater trochanter, lesser trochanter Posterior view Anterior view Gilroy, Anatomy: An Essential Textbook, Copyright © 2013 by Thieme Coxal Bone: Ilium Anterior superior Iliac iliac spine (ASIS) tuberosity Posterior gluteal The coxal bones (a.k.a., the Posterior superior Auricular surface hip bones) are iliac spine (PSIS) Sacroiliac joint also known as Posterior inferior PIIS the innominate iliac spine (PIIS) Anterior inferior bones because iliac spine (AIIS) they are made Ilium from the fusion of three smaller bones: the ilium, ischium, and pubis Acetabulum The coxal bones have many important bony features that serve as spatial Ischium Pubis landmarks and muscle attachments Medial view (right) Lateral views (right) Gilroy, Anatomy: An Essential Textbook, Copyright © 2013 by Thieme Coxal Bone: Ischium The ischium has two major landmarks, the ischial spine and ischial tuberosity, which are major muscle attachments and landmarks for the greater and lesser sciatic notches PIIS through which several Ilium neurovascular structures pass Greater sciatic notch Body Ischial spine Lesser sciatic notch Ischial tuberosity Ischium Medial view (right) Lateral views (right) Gilroy, Anatomy: An Essential Textbook, Copyright © 2013 by Thieme Coxal Bone: Pubis In proper anatomical position the anterior superior iliac spine and the pubic tubercle are in alignment Superior pubic ramus Pubic Body tubercle ASIS Body weight Inferior pubic ramus Ischiopubic ramus Obturator Pubic foramen tubercle Medial view (right) Lateral views (right) Gilroy, Anatomy: An Essential Textbook, Copyright © 2013 by Thieme  Pelvic Joints and Ligaments Lumbosacral joint The pelvic girdle is supported Supported by anterior longitudinal ligament and by ligaments, which offer iliolumbar ligaments stability while maintaining Sacroiliac joints some mobility of the joints Supported by sacroiliac ligaments Although these joints are very Posterior view stable, a traumatic event such as a difficult childbirth or Pubic car accident can tear symphysis the supporting separation ligaments and lead Pubic symphysis ‘Open book’ fracture to separation Anterior view Gilroy, Anatomy: An Essential Textbook, Copyright © 2013 by Thieme Pelvic Ligaments Sacrospinous ligament Inguinal ‘ligament’ Sacrotuberous ligament Posterior view Anterior view These ligaments serve as major landmarks and/or attachment points for muscles, as well as Obturator Lesser membrane stabilizing the pelvic joints sciatic foramen Medial view (right) Gilroy, Anatomy: An Essential Textbook, Copyright © 2013 by Thieme Hip Joint and Proximal Femur Head of the femur Neck of Greater the femur trochanter Lesser trochanter Gluteal Articular tuberosity surface …of acetabulum The head of the femur articulates with the acetabulum of the coxal bone to form the hip joint Acetabular fossa Major landmarks on the proximal femur serve as muscle attachments Lateral view (right) Gilroy, Anatomy: An Essential Textbook, Copyright © 2013 by Thieme Surface Anatomy Several landmarks on the coxal bone and femur can be palpated from the skin These serve as surface landmarks for various clinical assessments and interventions Can you locate all of these on yourself? Posterior view Anterior view Gilroy, Anatomy: An Essential Textbook, Copyright © 2013 by Thieme The ‘Femur Gun’ How do you tell a left femur from a right femur in the lab? Try using the ‘femur gun’! Greater trochanter Shaft Neck Lesser trochanter Head The lesser Hammer Barrel trochanter is the ‘trigger’, and should be easier to reach if Grip Trigger you’re holding the femur in the matching hand Butt Anterior view Gilroy, Anatomy: An Essential Textbook, Copyright © 2013 by Thieme  Hip Joint Shoulder Hip Anterior view Superior view Acetabulum Head of femur Like the shoulder, the hip joint is a ball-in-socket joint; however, it is much deeper, giving it more stability but less mobility Ball-in-socket joint Anterior view Gilroy, Anatomy: An Essential Textbook, Copyright © 2013 by Thieme  Movements at the Hip Lateral flexion Abduction of the trunk Same movement and Extension Flexion muscles as abduction Adduction Rotation Lateral view Medial and lateral As a ball-in-socket joint, the hip can perform a range of different actions that can be used in combination to provide Circumduction Combination of complex movements everything like circumduction Anterior views Drake, Gray’s Anatomy for Students, 2nd Ed., Copyright © 2009 by Churchill Livingstone Hip Joint and Femur: Sex Differences Q-angle Females > males Angle of inclination Males > females Although sex and gender exist on a spectrum, anatomists and clinicians examine the extremes of phenotypical sex to predict structure-function relationships and their clinical implications Knee problems in people with large Q-angle Lateral meniscus and medial collateral ligament (MCL) of the knee Anterior view Gilroy, Anatomy: An Essential Textbook, Copyright © 2013 by Thieme  Hip Joint and Ligaments Iliofemoral ligament Pubofemoral ligament Ischiofemoral ligament Synovial membrane Ligament of the head of the femur The spiral appearance of these ligaments is a result of medial twisting of the lower limb during embryological Sagittal view (right) development Posterior view Anterior view Gilroy, Anatomy: An Essential Textbook, Copyright © 2013 by Thieme Hip Joint Injury Two common hip injuries are dislocation and femoral neck fracture Anterior dislocation or femoral neck fracture Posterior dislocation https://tinyurl.com/y536bh83 https://tinyurl.com/yxqezd59 Hip replacement https://sgbonedoctor.com/ Gluteal Region Muscles NOTE! I have given you very detailed information about the muscles’ attachments. These are there for your reference and explanation purposes, but you do not need memorize them. You will find a muscle chart at the end of the lecture with the detail that you are expected to know. Fascia Gluteal fascia Covering the gluteal region Iliotibial band Thickening of fascia lata from muscle attachments Fascia lata Encircling the thigh The iliotibial (IT) band is a thickening of the fascia lata, which Crural facia encases the muscles Encircling the leg of the thigh and separates them into compartments Plantar facia On the plantar surface of the foot Gilroy, Anatomy: An Essential Textbook, Copyright © 2013 by Thieme Superficial Gluteal Muscles Gluteus maximus m. Origin: Tensor fasciae latae m. Posterior sacrum, Origin: sacrotuberous ligament Anterior superior iliac spine Insertion: Insertion: Iliotibial band, gluteal Iliotibial band → Tibia tuberosity (femur) Innervation: Innervation: Superior gluteal n. Inferior gluteal n. Gluteus medius m. Origin: Gluteal fossa (ilium) Insertion: Greater trochanter (femur) Innervation: Lateral view (left) Superior gluteal n. Copyright © Giovanni Rimasti The gluteus medius m. Greater trochanter is positioned such that it contributes to many actions at the hip Gluteal Sagittal view (left) tuberosity Gilroy, Anatomy: An Essential Textbook, Copyright © 2013 by Thieme Posterior view Posterior view  Deep Gluteal Muscles Gluteus minimis m. Origin: Gluteal fossa Insertion: Greater trochanter Innervation: Superior gluteal n. The gluteus minimus m. Lateral view (left) is similar to gluteus Copyright © Giovanni Rimasti medius m., but deeper. Note the many lateral hip Lateral hip rotators rotators – far more Piriformis m. Gemellus superior m. muscles contribute to Obturator internus m. Gemellus inferior m. lateral rotation than Quadratus femoris m. medial rotation of the hip Obturator externus m. (not visible) Posterior view Posterior view Gilroy, Anatomy: An Essential Textbook, Copyright © 2013 by Thieme Lateral Hip Rotator Muscles Innervated by direct branches from the sacral plexus Piriformis m. Origin: e.g., N. to piriformis, Anterior sacrum n. to quadratus femoris, etc. Insertion: Greater trochanter Although they all contribute to lateral rotation at the hip, some muscles also contribute to contradictory actions, Obturator internus m. Origin: like abduction by the piriformis m. Obturator membrane Insertion: versus adduction by the quadratus Greater trochanter femoris m. The obturator internus m. takes a Quadratus femoris m. unique 90˚ turn through the lesser Origin: Ischial tuberosity sciatic foramen as it travels between Insertion: Intertrochanteric crest its origin and insertion Posterior view Gilroy, Anatomy: An Essential Textbook, Copyright © 2013 by Thieme Lateral Hip Rotator Muscles Innervated by direct branches from the sacral plexus e.g., N. to piriformis, Gemellus superior m. n. to quadratus femoris, etc. Origin: Ischial spine Insertion: Obturator internus tendon The gemellus superior and inferior mm. are special because they attach onto the tendon of obturator internus m. on its way to the greater trochanter In cadaveric specimens, this gives the appearance of a cream filling Gemellus inferior m. Origin: (obturator internus m.) between Ischial tuberosity Insertion: two cookies (gemellus superior and Obturator internus tendon inferior mm.), like an Oreo Posterior view Gilroy, Anatomy: An Essential Textbook, Copyright © 2013 by Thieme Lateral Hip Rotator Muscles The obturator externus m. attaches on the anterior aspect of the obturator membrane, but crosses to the posterior side of the femur to reach the greater trochanter Unlike the other lateral hip rotators, which are back-to- Anterior view back muscles, this front-to- Obturator externus m. back muscle also contributes Origin: to lateral rotation at the hip Obturator membrane Insertion: Greater trochanter Innervation: Obturator n. Posterior view Agur and Dalley, Grant’s Atlas of Anatomy, 13th Ed. Copyright © 2013 by Lippincott Williams and Wilkins Neurovasculature  Aorta Arteries of the Lower Limb External The blood supply to the lower limb iliac a. Popliteal a. all starts anteriorly with the femoral Femoral a. a., which crosses posteriorly at the Deep femoral a. Anterior thigh popliteal fossa (behind the knee) Posterior thigh via Adductor magnus m. perforating branches before splitting to supply the different compartments of the leg and the foot Sagittal view Femoral a. Posterior tibial a. Its major branch, the deep Posterior leg femoral a., gives branches that Posterior view perforate (i.e., pierce) the adductor Fibular a. Anterior view Lateral leg Anterior magnus m. to supply the posterior tibial a. Perforating compartment of the thigh Anterior leg branches The medial compartment of Dorsalis the thigh is supplied by the Medial pedis a. obturator a. (not shown) plantar a. Dorsal foot Plantar foot Gilroy, Anatomy: An Essential Textbook, Copyright © 2013 by Thieme Gluteal Region Arteries Abdominal (descending) Branch from aorta obturator a. Small amount of Common Anterior view blood supply to iliac a. Superior head of femur and its ligament gluteal a. Gluteal region External Internal iliac a. iliac a. Branches from Inferior gluteal a. femoral a. Femoral a. Gluteal region Primary blood supply to Anterior thigh head and neck of femur Obturator a. Medial thigh The gluteal region Deep femoral a. is supplied by the Posterior thigh via perforating branches Perforating branches superior and of deep femoral a. inferior gluteal aa. Posterior thigh Posterior view Anterior view Agur and Dalley, Grant’s Atlas of Anatomy, 13th Ed. Copyright © 2013 by Lippincott Williams and Wilkins  Veins of the Lower Limb Inferior vena cava Lateral view Common iliac v. External iliac v. External iliac v. Deep veins follow the Femoral v. same pathways and Great naming as arteries saphenous v. Popliteal v. Great saphenous v. Small saphenous v. Like in the upper limb, Anterior view however, the superficial veins are a bit different… Dorsal venous arch Drake, Gray’s Anatomy for Students, 2nd Ed., Copyright © 2009 by Churchill Livingstone Gilroy, Anatomy: An Essential Textbook, Copyright © 2013 by Thieme Lumbosacral Plexus Don’t worry! We will not go into the same detail as we did for the brachial plexus… we will only examine the terminal branches Lumbosacral plexus (L1 – S4) Lumbar plexus (L1 – L4) Femoral n. (L2 – L4) Anterior thigh (hip flexors, knee extensors) All of the innervation Obturator n. (L2 – L4) to the lower limb Medial thigh (hip adductors) comes from the lumbosacral plexus, which is formed by two different Sacral plexus (L4 – S4) plexuses, the lumbar Sciatic n. (L4-S3) Posterior thigh (hip extensors, knee flexors) plexus and the sacral plexus, which are Tibial n. (L4 – S3) Posterior leg (knee flexors, plantarflexors, intrinsic foot) connected by the Common fibular n. (L4 – S2) lumbosacral trunk Anterior and lateral leg (dorsiflexors, evertors, digit extensors) Gilroy, Anatomy: An Essential Textbook, Copyright © 2013 by Thieme  Gluteal Region Nerves The superior gluteal n. and a., emerge through the greater sciatic foramen superior to the piriformis m., while Lumbar plexus the inferior gluteal n. and a. emerge inferior to it Lumbosacral trunk Superior gluteal n. Sacral plexus Inferior gluteal n. Sciatic n. Common fibular n. Tibial n. Posterior view Anterior view (right) Gilroy, Anatomy: An Essential Textbook, Copyright © 2013 by Thieme Posterior view (left) Agur and Dalley, Grant’s Atlas of Anatomy, 13th Ed. Copyright © 2013 by Lippincott Williams and Wilkins Dermatomes vs. Nerve Maps Remember, nerves can contribute to more than one dermatome, and more than one nerve can contribute to Obturator n. the same dermatome! Both contain For example, look how this L2 – L4 nerve map compares to the Femoral n. dermatome map when we Anterior femoral cutaneous n. overlay the two, paying specific attention to the obturator n. and femoral n., which both contain fibers from L2 – L4 and, therefore, have overlapping contributions Anterior views Drake, Gray’s Anatomy for Students, 2nd Ed., Copyright © 2009 by Churchill Livingstone Simplified Muscle Chart Attachments Muscle Group Muscle Origin Insertion Main action(s) @ hip Innervation Gluteus maximus Proximal femur, IT band Extension, lateral rotation Inferior gluteal n. Gluteus medius Gluteal fossa Gluteal Greater trochanter Abduction, rotation Gluteus minimis Superior gluteal n. Tensor fascia lattae ASIS IT band Abduction, medial rotation Gemellus superior Ischial spine Obturator internus tendon Gemellus inferior Lateral rotation Ischial tuberosity Direct branches from Quadratus femoris the sacral plexus Lateral hip rotators (e.g., nerve to ___) Abduction, lateral rotation, Piriformis Anterior sacrum extension Greater trochanter Obturator internus Obturator Lateral hip rotation membrane Obturator externus Obturator n. Upper vs. Lower Limb Use this chart to compare and contrast the upper and lower limbs. There are a lot of similarities, but also a lot of differences, which highlight important functional differences between the limbs Learning Outcomes By now, you should better understand how to… Identify and describe the bones related to the hip joint and the ligaments that stabilize it Explain the basic movements that occur at the hip Identify the intrinsic muscles of the hip and gluteal region, explain their innervations, and describe their functions Predict functional implications of nervous and musculoskeletal injuries to the hip and gluteal region